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Full text of "Infantile paralysis in Vermont, 1894-1922"

University of 

Connecticut 

LIBRARIES 
GIFT OF 

Health Sciences Library 

at 

Hartford Hospital 



INFANTILE PARALYSIS 
IN VERMONT 

1894-1922 



PRINTED BY 

THE VERMONT PRINTING COMPANY 

BRATTLEBORO, VERMONT 



INFANTILE PARALYSIS 
IN VERMONT 



1894-1922 



3 memorial to 
CHARLES S. CAVERLY, M.D. 




BURLINGTON, VERMONT 
STATE DEPARTMENT OF PUBLIC HEALTH 

1924 



Copyright 1924 

by State Department of Public Health 

Burlington, Vermont 



PRINTED IN THE UNITED STATES OP AMERICA 



T,a3 



PREFACE 

THIS volume has been prepared as a 
memorial to Dr. Charles S. Caverly. 
It consists, in the main, of his writings 
on the subject of poliomyelitis in Ver- 
mont, to which are added certain con- 
tributions from the men who worked 
with him or after him, and a statement 
of the present status of the work 
instituted by him. 



Digitized by the Internet Archive 
in 2013 



http://archive.org/details/infantileparalysOOcave 



CONTENTS 
Preface , 5 

Introduction 9 

Dr. Charles S. Caverly, a Biographical Note 13 

Contributions of Charles S. Caverly, M.D., 

Preliminary Report of an Epidemic of Paralytic 
Disease, Occurring in Vermont, in the Summer 
of 1894 15 

Notes of an Epidemic of Acute Anterior Polio- 
myelitis 21 

Anterior Poliomyelitis in Vermont in the Year 
1910 . 39 

Anterior Poliomyelitis in Vermont in 1911 .... 56 

Epidemic Poliomyelitis in Vermont in 1912 .... 69 

Epidemic Poliomyelitis, A Review of the Epi- 
demics of 1914 and 1915 97 

Infantile Paralysis (Poliomyelitis) in Vermont, 
1916-1917 144 

Contributions of the After-Care Department, 
The Treatment of Infantile Paralysis — Prelimi- 
nary Report Based on a Study of the Vermont 

Epidemic of 1914 201 

By Robert W. Lovett, M.D. 
Infantile Paralysis in Vermont — A Report of 
Progress of Cases between January, 1915, and 

July, 1915 232 

By Robert W. Lovett, M.D., and 
E. G. Martin, Ph.D. 

Certain Aspects of Infantile Paralysis 240 

By Robert W. Lovett, M.D., and 

E. G. Martin, Ph. D. 
The Spring Balance Muscle Test 252 

By Robert W. Lovett, M.D., and 

E. G. Martin, Ph. D. 

7 



A Plan of Treatment in Infantile Paralysis .... 263 
By Robert W. Lovett, M.D. 

History of the After-Care of Poliomyelitis in 
Vermont 275 

By Robert W. Lovett, M.D. 

Organization, Aim, and Plan of Work of the 
After-Care Department for Poliomyelitis in 

Vermont 302 

By Bertha E. Weisbrod, R.N. 

Contributions of the Research Department, 

A History of the Work in Poliomyelitis of the 
Research Laboratory, Vermont State Board of 

Health 307 

By W. L. Aycock, M.D. 

The Care and Treatment of Acute Poliomyelitis 

in Vermont 312 

By W. L. Aycock, M.D. 

Neutralization of the Virus of Poliomyelitis by 

Nasal Washings 318 

By Harold L. Amoss, M.D., and 
Edward Taylor, M.D. 

Carriage of the Virus of Poliomyelitis, with Sub- 
sequent Development of the Infection 337 

By Harold L. Amoss, M.D., and 
Edward Taylor, M.D. 

The Treatment of Acute Poliomyelitis — Prelimi- 
nary Note on Use of Hypertonic Salt Solution 
and Convalescent Human Serum 348 

By W. L. Aycock, M.D., and 

Harold L. Amoss, M.D. 

Experiments on Local Specific Therapy in Polio- 
myelitis — The Utilization of Hypertonic Solu- 
tions in the Serum Treatment of Experimental 
Poliomyelitis 355 

By W. L. Aycock, M.D., and 

Harold L. Amoss, M.D. 

8 



INTRODUCTION 

The question as to why man alone of all the animals 
became civilized is answered by one historian in this 
wise : "All animals gain a certain wisdom with age and 
experience, but the experience of one ape does not profit an- 
other. Learning among animals below man is individual, 
not cooperative and cumulative." This may or may not be 
the answer, but it is certainly true that today men have a 
feeling of what might almost be called moral obligation to 
pass on to others the things that they have found out for 
themselves. 

Although men may battle with men, and nations with na- 
tions, man knows neither personal grudge nor national en- 
mity in the fight against a common foe that threatens all 
mankind, such as disease. In the field of medicine and public 
health man has conquered and will continue to conquer only 
by cooperative effort and the benefit of cumulative experi- 
ence. The knowledge of the cause of a disease and its treat- 
ment must not die with him who discovered it ; and when a 
disease is still unconquered it is quite as important that all 
the ground gained should be held, and all possible informa- 
tion as to the enemy's strength and weakness should be 
known to those who are still fighting the battle. 

Infantile paralysis, or poliomyelitis, still baffles science 
as to its cause and prevention ; and while not a new disease, 
having been fairly well described by Michael Underwood as 
early as 1774, it has occurred in epidemic form only in com- 
paratively recent years. The first known epidemic of any 
considerable size in the United States occurred in Vermont 
in the summer of 1894. This was reported by Dr. Charles S. 
Caverly, President of the State Board of Health. 

Not only was Vermont to be associated with the history 
of infantile paralysis because of this first epidemic, but 



10 INFANTILE PARALYSIS IN VERMONT 

later epidemics made heavy inroads upon the comparatively 
small population of the state, leaving many crippled chil- 
dren to be cared for. This situation became so serious that 
after an epidemic of 306 cases in 1914, through the efforts 
of Dr. Caverly and the generosity of an anonymous friend 
of the state whose interest he enlisted, a special fund was 
provided for the study of the cause and treatment of infan- 
tile paralysis. 

Thus it happened that from being the first state in which 
the disease occurred in epidemic form, Vermont also became 
the first to undertake on a state-wide scale the after-care 
of the victims of infantile paralysis. The special fund, as 
stated, also provided for research as to the cause and trans- 
mission of the disease, and in this field, too, much valuable 
knowledge has resulted from the efforts of those carrying 
on the work. 

The history of infantile paralysis in Vermont really falls 
into three divisions: (1) the epidemiologic study of the dis- 
ease; (2) the treatment of affected cases; and (3) the work 
of the research department. It is the belief of those who 
have been connected with the work that the data collected 
along these lines form a contribution to the knowledge of in- 
fantile paralysis and are worthy of permanent record. They 
are therefore compiled in this present form. In the pages 
that follow will be found Dr. Caverly's collected reports on 
the epidemiology of the disease; certain articles by Dr. 
R. W. Lovett and those working with him on the plan of 
state-wide treatment adopted, and the results of this treat- 
ment; and the data obtained from the laboratory studies 
conducted by the research department under the supervis- 
ion of Dr. Simon Flexner and carried on by Dr. H. L. 
Amoss, Dr. Edward Taylor and Dr. W. L. Aycock. 

No piece of constructive work of any magnitude was ever 
accomplished by one man alone, but it is usually true that 
long before the first step is taken the idea has assumed defi- 



INTRODUCTION 11 

nite form in the mind of one person, who is the leader and 
inspiration of the other workers. He has seen the need and 
has caught the vision of the goal to be achieved. Perhaps, 
as the plans grow and the work develops, it may go beyond 
the fondest dream of him who gave it its first impulse, or it 
may never reach the goal which he foresaw. Dr. Caverly did 
not live to see the disease against which he had fought so 
long and so untiringly really conquered and the fear of fu- 
ture epidemics removed ; but he did live to see many of the 
victims of infantile paralysis in Vermont well on the road to 
happy, useful, and in some cases normal lives, and to know 
that real contributions to the knowledge of the disease had 
been made by those working in cooperation with the State 
Board of Health under his presidency. 

The fight against infantile paralysis is by no means ended, 
and the disease still presents to the medical profession a 
most perplexing problem. In so far as this volume may be 
of use to those engaged in its solution, it is hoped that 
it may be worthy of the memory of him to whom it is 
inscribed — Dr. Charles S. Caverly, a leader and tireless 
worker in the field of the treatment and prevention of infan- 
tile paralysis, President of the Vermont State Board of 
Health from 1891 until the time of his death in September, 
1918. 



DR. CHARLES S. CAVERLY 

DR. CHARLES SOLOMON CAVERLY was born in 
Troy, New Hampshire, September 30, 1856, and 
came of an old New England family, his great great- 
grandfather, Philip Caverly, having served as a soldier in 
the Revolutionary War. He was educated in the high schools 
of Pittsf ord and Brandon, and prepared for college at Kim- 
ball Union Academy, in Meriden, New Hampshire. In 1878 
he graduated from Dartmouth College, where he was a 
member of the Phi Beta Kappa ; and after receiving the de- 
gree of A.B. there he went to the University of Vermont, 
from which he received the degree of M.D. in 1881. Here he 
was class leader and the recipient of three prizes. Subse- 
quently he studied for eighteen months at the College of 
Physicians and Surgeons in New York, and began practice 
in Rutland, Vermont, in 1883, being associated with Dr. 
Middleton Goldsmith. 

Although always successful in private practice, his inter- 
est in public health movements became evident at an early 
date. He became a member of the Vermont State Board of 
Health in 1890, and its President and animating spirit in 
1891, which office he held until the time of his death. He 
was also Professor of Hygiene and Preventive Medicine at 
the University of Vermont, from which he received the 
honorary degree of Sc.D. on account of his distinguished 
service in the interest of public health. He died October 16, 
1918, after a brief period of influenza with complications. 

Early in his work Dr. Caverly became interested in polio- 
myelitis, and in December, 1894, he published in the New 
York Medical Record an article describing the epidemic oc- 
curring in Vermont in the summer of that year. This report 
stood out as the best contribution, in America at least, to 
our knowledge of the disease up to that time. He recognized 

13 



14 INFANTILE PARALYSIS IN VERMONT 

the abortive cases, which were not so named and recognized 
until a great many years later, and he gave a very intelli- 
gent and advanced account of the behavior of the affection. 
He never lost his interest in the condition, and his biennial 
reports on infantile paralysis in Vermont have been of great 
value to the medical profession. 

In 1914, when an epidemic of 306 cases occurred in the 
state, he set seriously to work to see what could be done to- 
ward helping our knowledge of the disease. Vermont is a 
small state with comparatively few inhabitants, and 306 
cases represented a very high incidence. In this year and 
in subsequent years he gave a great amount of time to the 
direction of the work for the care and prevention of polio- 
myelitis, in which he was intensely interested and with 
which he was actively associated up to the time of his death. 

Dr. Caverly was also very deeply interested in the cure 
and prevention of tuberculosis, and his help in the establish- 
ment and work of the Pittsford Sanitorium, and later the 
Preventorium at Essex, was very great. 

I knew him first in 1914, when I went at intervals to Ver- 
mont to conduct the treatment of the cases of infantile pa- 
ralysis there, and I was greatly impressed by his personality 
and his public spirit. We were thrown much together, and I 
became intimately acquainted with him, an intimacy which 
continued up to the time of his death. He was a quiet, cul- 
tivated man, with a singleness of purpose which was strik- 
ing, a lack of pretense which was always charming, and an 
ability which was perfectly evident. He was universally re- 
spected and looked up to for his attainments, his accom- 
plishments, and his personal character. He kept himself in 
touch with the progress of medicine in all departments ; his 
manner of conducting matters of business was always quiet, 
efficient, and unassuming ; and when he died he left behind 
him the feeling that a man of real ability, high personal 
character, and great usefulness had been taken away. 

Robert W. Lovett. 



PRELIMINARY REPORT OF AN EPIDEMIC OF 

PARALYTIC DISEASE, OCCURRING 

IN VERMONT, IN THE 

SUMMER OF 1894* 

By Charles S. Caverly, M.D. 

EARLY in the summer just passed, physicians in cer- 
tain parts of Rutland County, Vermont, noticed that 
an acute nervous disease, which was almost invaria- 
bly attended with some paralysis, was epidemic. The first 
cases observed occurred in the city of Rutland and the town 
of Wallingford, appearing about the middle of June. The 
disease prevailed chiefly in the city of Rutland up to about 
the middle of July, when other towns about this city began 
to report cases. 

From my own observation and conversation with other 
physicians, and the general feeling of uneasiness that was 
perceptible among the people in regard to the "new dis- 
ease" that was affecting the children, I determined during 
the last of July to undertake a systematic investigation of 
the outbreak, in my capacity as a member of the State 
Board of Health. I sought from all the physicians practic- 
ing in the area which I knew to be affected by the disease 
such information in regard to their own cases as it was pos- 
sible for them to contribute. This investigation, undertaken 
in an official capacity, soon convinced me that this region 
had been affected by an epidemic of nervous disease very 
rarely observed. 

For the reason that this outbreak is of such an unusual 
character and especially interesting to the general prac- 
titioner everywhere, I am sure that I shall be pardoned in 
using the facts which I have succeeded in collecting for the 
general benefit of the profession, as well as for the public. 

*From the Yale Medical Journal, November, 1894 

15 



16 INFANTILE PARALYSIS IN VERMONT 

It is yet too early to make a complete or exhaustive report 
of this epidemic. I will merely, in what I shall have to say 
in this article, briefly summarize the statistics which I have 
so far secured, and refer only incidentally to the exact na- 
ture of the disease. 

The cases, of which I have collected reports, more or less 
complete, number 123. They date from June 17th to Septem- 
ber 1st. The territory covered is mainly the narrowest part 
of the Otter Creek Valley in Rutland County, bounded on 
the east by the Green Mountain range and on the west by 
the Taconic range, having no natural boundaries north and 
south. This valley is approximately fifteen miles wide, in- 
cluding the sides of the bounding mountains, and thirty 
miles long. 

Of the 123 cases of which I have notes, all but six oc- 
curred in this valley. Through this valley flows the Otter 
Creek from south to north, a sluggish stream, which during 
the present summer is said to have been lower than ever 
before. The population is about 26,000, of which probably 
18,000 live in the manufacturing and quarrying centers of 
Rutland, Proctor and West Rutland. The towns which have 
been most affected by this epidemic are those immediately 
on the Otter Creek. I can best illustrate the character of the 
epidemic by citing a few cases of which I have reports. 

Case I was a boy three years old, American; previous 
health good ; very active child ; stronger than his brother a 
year or two older ; no apparent cause ; taken with moderate 
fever ; very irritable ; tongue coated ; an apparent attack of 
indigestion, though no diarrhoea or nausea. After two or 
three days, the febrile symptoms abated, and his parents 
called the attention of the physician to his inability to use 
his legs. The extensor muscles of the thigh seemed to be 
chiefly affected. He could not walk ; could not stand steadily 
for ten days. At the end of that time, he began to use his 
legs in walking by holding on to chairs, and in three weeks' 
time had fully recovered their use. 



PRELIMINARY REPORT 17 

Case II was a boy, three and one-half years old, Irish, 
sturdy child, one of three or four children. The only appar- 
ent cause, playing too hard on a hot day. Had fever, 102° 
to 104°, for two days; incontinence of urine for ten days. 
On the third day paralysis of both legs. Loss of patellar re- 
flex; considerable hyperesthesia. After the initial symp- 
toms had subsided, there was only slight reaction in the 
muscles of both lower extremities to faradism. After two 
weeks the right leg improved rapidly, the left not so fast. 
After six weeks he was able to take hold of chairs and walk 
a little. The paralysis and wasting, after ten weeks, was 
confined to the left gluteal and lower spinal muscles and has 
resulted in spinal curvature. 

Case XCIII was a boy, two years old, American; first 
had an attack of indigestion, from which he apparently re- 
covered, when he was taken for a long carriage drive and 
at once developed fever with erythematous rash over the 
body; some muscular rigidity of the neck and back, and, 
after a few days, paralysis in both legs with loss of patellar 
reflex. After two months has not improved much. 

Case CXIV was a boy, six years old; previous health 
good; apparent cause, chilling the body when heated; had 
high fever, temperature 104°; vomiting; acute symptoms 
lasting six days. On the sixth day had paralysis of the right 
arm, followed on the seventh by paralysis of the left leg. 
The extensors of the left thigh and right deltoid muscles 
are now paralyzed (aften ten weeks) and somewhat wasted. 

Case IV was a boy, six years old ; was taken with convul- 
sions while playing in the street, convulsions lasting nine 
hours; moderate fever, rapid pulse; vomiting; muscular 
rigidity of the neck and back ; hyperesthesia of extremities ; 
very restless, no paralysis noted ; death on the sixth day. 

These cases are fair illustrations of those encountered 
through this epidemic. The cases have not been confined to 
children. I find one case reported in a man seventy years 



18 INFANTILE PARALYSIS IN VERMONT 

old, who exhibited almost the same train of symptoms as a 
child in a mild form of this disease. He lost the use of both 
legs for seven days and after that rapidly recovered their 
use. 

I find also several cases among persons from fifteen to 
forty years of age, and several deaths. The ages of those 
reported were as follows : Under six years, eighty-four ; six 
to fourteen years, twenty; over fourteen years, twelve. 
Stated as "between a few months and nine years," seven. 

I find that the sex of those under six years of age, where 
stated, was exactly twice as often males as females. Over 
fourteen years of age, the same ratio prevailed. Of those be- 
tween six and fourteen whose ages are given, nine were 
males and two females. The number of those stated to have 
had some form of paralysis is 110. Of this number fifty 
have fully recovered at the time of my report, ten had died, 
leaving fifty who were apparently permanently disabled. 
The exact location of the initial paralysis when it occurred, 
and that still left at the time my reports are made, I have 
not as yet had time to tabulate. Of the 123 cases of which I 
have reports, seven died very early and before any paralysis 
was noted, six are definitely stated to have had no paralysis, 
one of which died. 

It is noted that there have been several degrees of se- 
verity in the disease which has prevailed here, or else there 
have prevailed several diseases. Case I, whose history I 
have given, represents fairly the mildest cases. Cases II, 
XCIII and CXIV represent the cases that appear now to be 
permanently disabled, while Case IV is a fair sample of 
those which have died. 

It will readily occur to physicians that the symptoms 
noted in these cases are suggestive of two diseases, Cerebro- 
spinal Meningitis and Acute Anterior Poliomyelitis. The in- 
itial fever, followed in a few days by definite motor paraly- 
sis, of which a certain percentage recover in a few weeks, 



PRELIMINARY REPORT 19 

the rest suffering permanent impairment of some muscles, 
offers a fair picture of the average case of Poliomyelitis 
Anterior, while the high fever, muscular rigidity, and hy- 
peresthesia, are not characteristic of this disease. 

The season of the year, the absence of special sense symp- 
toms, especially deafness, as a sequella in this epidemic, the 
low mortality, the absence of the very characteristic pur- 
puric eruption, are strong arguments against the theory of 
Cerebro-Spinal Meningitis. It is now well established that 
the other disease, Poliomyelitis, is occasionally epidemic. 
Such epidemics have been noted in at least three instances 
in Europe, and one is reported by Putnam as occurring near 
Boston. The Stockholm epidemic reported by Medin is in 
many respects quite similar to the one which I have re- 
ported. 

Without going further into the matter of diagnosis, as I 
do not as yet feel warranted in doing, I may say that Dr. 
A. Jacobi, of New York, whose opinion I am permitted to 
quote, pronounces this epidemic one of Cerebro-Spinal Men- 
ingitis. I should state that Dr. Jacobi's knowledge of our 
epidemic has been gained solely from my written descrip- 
tion to him. Dr. M. Allen Starr, who has taken much inter- 
est in this epidemic and has seen ten cases in the chronic 
stage, very kindly allows me to quote him as of the opinion 
that the features of our epidemic resemble more nearly 
Poliomyelitis than Cerebro-Spinal Meningitis. Dr. Charles 
L. Dana, whose knowledge of this epidemic is likewise 
gained from what I have written him in regard to it, and 
from the partial examination of the brain and cord of a 
fowl which had paralytic symptoms and was taken from a 
flock in this section that was dying of symptoms suspicious 
of a nervous disease, says as follows : 

"I can most positively state my opinion to be that your 
cases were mostly cases of Anterior Poliomyelitis. ,, It may 
be remarked that the microbic or infectious nature of the 



20 INFANTILE PARALYSIS IN VERMONT 

disease is generally believed in by us, whose opportunities 
for observing it have been merely clinical. Further investi- 
gation on the brain and cord of the lower animals we hope 
may throw some light on this point. There is no evidence 
of its contagiousness, since it has affected almost invariably 
but a single member of a household. 

.1 might state further that there have been many deaths 
among horses, attended with symptoms of paralysis, and in 
which at least one veterinarian tells me he found menin- 
gitis. There have been, too, some deaths with similar symp- 
toms among dogs and fowls. 

This report is the merest outline of this epidemic, but as 
I secure fuller facts and have time, I hope to record a com- 
plete history of this interesting outbreak. The 123 cases, 
with eighteen fatalities, probably represent eighty-five or 
ninety per cent of all that have occurred. It was utterly 
impossible to secure in any of the fatal cases an autopsy. 

For the data on which these observations are founded, I 
am under obligations to the profession generally through- 
out this region, who have responded with uniform prompt- 
ness to my request for facts. 

Rutland, Vt, Oct, 189 Jf. 



NOTES OF AN EPIDEMIC OF ACUTE 
ANTERIOR POLIOMYELITIS* 

By Charles S. Caverly, M.D. 

THE following "Notes" are the result of an investiga- 
tion undertaken by me in an official capacity at the 
time of the outbreak, and since continued through pri- 
vate and professional intercourse. 

The epidemic was one of an acute nervous disease whose 
chief distinguishing characteristic was motor paralysis, 
more or less complete, of one or more members or groups 
of muscles, and which prevailed in the State of Vermont, 
chiefly in a single valley, during the summer of 1894. The 
results of my investigations, as far as completed at the time, 
were published in the Yale Medical Journal for Nov., 1894, 
and in the New York Medical Record for Dec. 1, 1894. At 
the time of making these reports, it did not seem possible to 
speak of the epidemic more definitely than as one of "acute 
nervous disease of unusual type." A further careful study 
of the complex features of the epidemic, however, and of 
the subsequent history of many of the cases, together with 
the corroborative opinions of many able medical men, seems 
to clear up any doubt that at the time existed as to the cor- 
rect diagnosis of the essential disease that prevailed. 

I may state at once that I am indebted to Professors A. 
Jacobi, M. Allen Starr and Chas. L. Dana for very valuable 
aid in arriving at a diagnosis in this series of cases, as well 
as for notes of the latest pathologic views of poliomyelitis 
and a literary resume of that disease. I am also indebted to 
my fellow practitioners of Vermont who have kindly placed 
at my disposal the results of their clinical observations of 
the epidemic. This paper is necessarily largely a recapitula- 

*Read in the Section on Neurology and Medical Jurisprudence at the 46th Annual 
Meeting of the American Medical Association, at Baltimore, Maryland, May 7-10, 1895. 
Reprinted by permission from J. of A. M. A., 1896, XXVI, 1. 

21 



22 INFANTILE PARALYSIS IN VERMONT 

tion of the facts heretofore published about this epidemic, 
with a careful revision of the statistics of the outbreak made 
from recent observations. 

The epidemic, as I have indicated, invaded our valley in 
the early summer of 1894. It prevailed with increasing se- 
verity during July, apparently reached its climax about the 
first of August, and steadily declined until about the first of 
October, the last case occurring early in that month. 

The early summer was popularly considered unusually 
hot and dry, though the official figures do not substanti- 
ate the former opinion. That it was an exceptionally dry 
season is manifest from the figures of the United States 
Weather Bureau of the State, which show that the rainfall 
during the five months from April to August, inclusive, for 
this year was one-third less than the average for these 
months since the opening of the station in the State. The 
temperature and humidity statistics show little variation 
from the average. The territory mainly covered by this out- 
break is a portion of the Otter Creek Valley, about thirty 
miles long and from twelve to fifteen wide, including the 
sides of the bounding mountains. On the east of this part 
of the valley is the main Green Mountain range, and on the 
west the Taconic range, which is a northern extension of 
the Berkshire Mountains of Massachusetts. Otter Creek, the 
largest stream of water in the State, has its source in the 
mountains to the south of the affected area, and sluggishly 
flows in a northerly direction through it, emptying some 
miles below into Lake Champlain. That part of its course 
through the affected district is the most populous and like- 
wise the narrowest part of the valley. The city of Rutland 
is the commercial and geographical center of this area. The 
towns affected have a combined population of 26,000, of 
which fully two-thirds dwell in the quarrying and manu- 
facturing centers of Rutland, West Rutland and Proctor. 

The starting point of the epidemic, and most of the earlier 



NOTES OF AN EPIDEMIC 23 

cases, were at Rutland. In this city occurred 55 of the 132 
cases of which I have notes; 27 of the remainder occurred 
in the town of Proctor, one-sixth the population of Rutland. 
This town suffered the worst of any in the valley. The re- 
maining fifty cases were scattered over the rural districts 
in fourteen towns. The most of these cases occurred at con- 
siderable elevation above the creek, and many well up on 
the Green Mountains. Four of these towns with eight of 
the cases are not in the Otter Creek Valley. The natural 
drainage of the valley is the creek, and this stream, below 
Rutland, carries a large amount of sewage. If the disease 
had shown any preference for those houses immediately on 
the stream below Rutland, it might at once be inferred that 
the low water in a sewerage-contaminated stream had some 
bearing on the etiology of the disease. But such did not ap- 
pear to have been the case, except possibly, in the town of 
Proctor, which is six miles below Rutland and is built on 
the abrupt bluffs above the stream. Drainage defect in 
general did not seem to influence the distribution of the dis- 
ease. The water supply was excluded as an etiologic factor, 
it being largely from wells in the rural communities, and in 
the villages from mountain streams and springs. That the 
general sanitary surroundings and methods of living were 
in anywise responsible for the outbreak is also more than 
doubtful, since the disease showed no partiality to that class 
of the population whose habits and surroundings are the 
most unsanitary. The so-called laboring classes were often- 
est affected, but not out of proportion to their numbers. 
These classes here, whether among the farming population 
or in the mills and quarries, have usually pure air, food and 
water. Hence, general sanitary conditions did not seem 
to have any influence on the epidemic. 

The geologic formation of the valley is not peculiar. The 
prevailing formation is limestone, and in the range that 
skirts the western border of the valley is found the chief 



24 INFANTILE PARALYSIS IN VERMONT 

marble deposit of Vermont. The valley as a whole is an old 
lake basin and is pronounced by Prof. G. W. Perry, the 
State Geologist, as a very ordinary valley. 

The outbreak of which I speak consisted of upward of 
130 cases of disease in which the commonest clinical mani- 
festation was some degree of motor paralysis of widely va- 
rying extent. It will not surprise any one that so large a 
number of cases presenting a bewildering variety of initia- 
tory constitutional symptoms, as well as local paralyses, 
should have proved a very knotty problem for the diagnos- 
tician. It was long a question whether this was an epidemic 
of one, two, or more diseases, and along the established lines 
of symptomatology and pathology there was no solution of 
the problem. I have been able to collect histories more or 
less complete of 132 cases directly affected in this epidemic, 
and this number probably represents at least 90 per cent of 
the whole number. 

Case 1. Boy, 3 years, American. Hygienic surroundings 
good ; previous health good ; active child ; stronger than his 
brother two years older. No apparent cause. Fell sick June 
20. Moderate fever, coated tongue, loss of appetite, sluggish 
bowels. His condition was confidently ascribed to indiges- 
tion, and after two or three days the continuance of the 
symptoms, though in decreasing severity, proved trouble- 
some of explanation. On the third day his parents insisted 
that he could not use his legs. It was soon evident that this 
was the case. His reflexes were normal, sphincters unaf- 
fected, no anesthesia or noticeable hyperesthesia. The weak- 
ness was most marked in the large extensors of the thigh. 
After the entire subsidence of his febrile symptoms, his 
muscular weakness began to improve, at first very slowly. 
In three weeks he had gone on to full recovery. 

This case is an excellent illustration of the mildest type 
of the disease, a type that included about forty cases. 

Case 2, Boy, 3^ years, Irish. Hygienic surroundings 



NOTES OF AN EPIDEMIC 25 

fair ; sturdy child ; most active of a family of three children. 
Only apparent cause playing too hard on a hot day. Taken 
with high fever, temperature 102° to 104° F., nausea, gen- 
eral restlessnes and headache. Had incontinence of urine, 
no albuminuria. On third day acute symptoms subsided ex- 
cept the incontinence of urine. It was then noticed that he 
had lost the use of his legs. Patellar reflexes diminished 
and considerable hyperesthesia of the legs. There was also 
diminution of f aradic irritability. The left leg improved ra- 
pidly, the right slowly. After six weeks was able to stand 
and take a few steps by taking hold of chairs. After three 
months the paralysis and wasting were confined to the right 
glutei and lower spinal muscles. His efforts to walk have 
brought on a slight spinal curvature. The incontinence of 
urine continued in this child until Feb. 1, 1895, when it was 
relieved by circumcision. The paralysis, however, persists 
in the glutei and lower spinal muscles and promises to be 
permanent. 

This case illustrates a very common phase of this epi- 
demic, and in most of these cases there is probably some 
permanent impairment of certain muscles. 

Case 88. Practice of Dr. Gale, Rutland. Girl, 6 years, 
American. Previous health had been frail. Had had a spinal 
curvature since she began to walk. Taken suddenly with 
high fever, nausea, head- and backache. On the fourth day 
of the attack she was paralyzed in all the extremities and 
one side of the face. Febrile symptoms subsided at this 
time. There was extreme hyperesthesia of the whole body 
and obstinate constipation from seeming lack of power in 
the abdominal muscles. Facial paralysis speedily passed off. 
Hyperesthesia and pains in the joints required the use of 
morphine for several weeks. After nine months she is still 
paralyzed in all the extremities, being able to flex the fin- 
gers and toes slightly and raise the head. The hyperesthesia 
has passed off. 



26 INFANTILE PARALYSIS IN VERMONT 

Case 116. Practice of Dr. Swift, Pittsford. Boy, 4 years, 
Italian. Taken with headache, drowsiness and slow hob- 
bling pulse. Little fever. After four days developed stra- 
bismus. Improved speedily and at the end of four days was 
apparently well. Three days later, after playing too hard, 
had a return of the original symptoms. Headache, drowsi- 
ness, no fever, pulse 45. In two days from this time had a 
convulsion and speedily died. 

Case 32. Practice of Dr. Marshall, Wallingford. Woman 
21 years. Married and one child of 16 months. Apparent 
cause fatigue from nursing sick child. First had head- and 
backache. Pulse 80, temperature 98.6°. On third day pulse 
100, temperature 103.5°. Some opisthotonos; bowels regu- 
lar; urine, 2 pints in twenty-four hours. No albumin, no 
sugar. Urticarial blotches on the body. During the next 
three or four days temperature ranged from 100.5° to 102°, 
pulse about 100. Was unable to speak or swallow. Answered 
questions by moving the head; in no pain. Sixth day tem- 
perature 98.6° ; pulse 60. Remained in this condition five 
days. On the eleventh day complained of severe pain in the 
stomach, and neck became rigid; pulse 100, temperature 
98.6°. During the next two days pulse became very irregu- 
lar. Complained of severe pain in the right side of the head 
and right eye. Died at the end of the second week. 

Case U. Practice of Dr. Fox, Rutland. Boy, 6 years, previ- 
ous health fair. On two or three occasions had convul- 
sions, presumably due to gastro-intestinal disturbance. Was 
seized, with convulsions while playing on the street ; they 
continued for nine hours. Moderate fever, rapid pulse, 
vomiting and rigidity of muscles of the neck and back. No 
paralysis noted during conscious intervals. Retention of 
urine during the last three days of illness. Death on the 
sixth day. 

These four cases represent various types of the severe 
form of the disease ; among these cases there were eighteen 
deaths. 



NOTES OF AN EPIDEMIC 27 

There were a great many cases exhibiting rare and inter- 
esting phenomena, a detailed report of which would con- 
sume too much time. One of these, during an attack of 
broncho-pneumonia, had loss of speech for two weeks, and 
paralysis of one arm which recovered in five weeks. One 
developed paralysis of both legs in connection with pneu- 
monia. The paralysis in one case was confined to the ex- 
ternal rectus of one eye. Several, after apparently recover- 
ing from the acute symptoms, were again attacked more 
severely than at first. Two cases, in which the legs were 
paralyzed, had a concurrent fever with the characteristic 
typhoid curve. One case was that of a boy of 6 years who 
had been at the seashore during the summer, and returning 
to the town of Proctor after the epidemic was apparently 
on the wane, on September 5, was attacked with the typical 
symptoms of poliomyelitis on September 30, and is left with 
impairment of the extensors of one thigh and the glutei. 
This case is interesting as showing possibly the length of 
the incubation period of the poison if we class the disease 
among the infectious disorders. 

Without detailing further individual cases, a condensa- 
tion of my notes presents the following clinical picture of 
the epidemic: 

Age and Sex. — Ninety cases were under 6 years of age; 
39 were boys and 22 girls ; sex of the remainder not stated. 
Fifteen cases were between the ages of 6 and 14; 5 were 
males and 6 females ; sex not stated in 4 cases. Fifteen cases 
were over 14 years ; 9 were males and 6 females. In one se- 
ries of cases, 7 in number, the age is stated as between "a 
few months and 9 years," and the sex of none is given. In 
another of 5 cases, neither age nor sex is stated. It is inter- 
esting to note in this connection that there were 9 cases in 
adults upward of 21 years of age. One of these was a man 
of 70 who had the familiar symptoms of the milder type of 
these cases with paralysis of both legs, which passed off in 



28 INFANTILE PARALYSIS IN VERMONT 

ten days. The other 8 cases were in persons from 21 to 38 
years of age. These figures as to age and sex do not differ 
from those usually given for poliomyelitis. While it is 
chiefly a disease of childhood it is not exclusively so. Males 
are vastly more liable to it. 

Nationality. — In those cases in which the nationality is 
stated 41 were American, 17 Irish, 6 French, and one each 
was Hebrew, Italian and Swede. I know of no significance 
to attach to these figures. 

Previous Health. — Of the 46 cases in which the previous 
health of the sufferers is given, in 35 it is given as good, 
and in 11 as poor. It is quite certain that the strong, healthy 
children preponderated. 

Immediate Cause. — The immediate apparent cause is 
stated in 37 instances. Of these overheating is mentioned 
24 times, chilling of the body 4 times, trauma 4 times, while 
fatigue, typhoid fever, pneumonia and whooping cough are 
mentioned. There was a general absence of infectious dis- 
ease as an etiologic factor in this epidemic. The element of 
contagium does not enter into the etiology either. I find but 
a single instance in which more than one member of a fam- 
ily had the disease, and as it usually occurred in families of 
more than one child, and as no efforts were made at isola- 
tion, it is very certain that it was non-contagious. 

Initial Symptoms — Fever. In most of the cases there was 
a perceptible rise in temperature at the start, though a few 
are said to have had none. Of the 56 cases in which the 
temperature is noted, 27 had a temperature at some time of 
103° or more, while in 26 it ranged from 99° to 103°. Three 
are said to have had "no fever." The duration of the initial 
fever, where given, varied from a few hours to two weeks. 
The four cases, however, that are said to have had a fever 
for more than a week, probably suffered from some compli- 
cation or some intercurrent disease. Twenty-six cases had 
a febrile stage lasting from four to seven days, 7 lasting 



NOTES OF AN EPIDEMIC 29 

from three to four days, 6 lasting two or three days, 2 last- 
ing one to two days, and four for one day or less. 

Digestive Organs. — Nausea was a very common symptom 
and is mentioned as occurring twenty-six times. It was 
often the first symptom noted and was probably one of 
the commonest. Gastralgia occurred in few cases. Thirteen 
cases were said to have had obstinate constipation, and six 
had a diarrhea. 

Urinary Organs. — Two cases had incontinence of urine 
and in ten cases there was retention. In no case is albu- 
minuria mentioned. 

Skin. — Thirty cases are said to have had a simple ery- 
thema, and two had urticaria. There was an entire absence 
of herpetic and purpuric eruptions. 

Nervous System. — Convulsions occurred in 12 cases, all 
under 14 years of age. Muscular rigidity of the neck or 
back muscles, or both, is said to have occurred in 20 cases, 
of which 5 were fatal. It is a very significant fact that 36 
cases are noted as having hyperesthesia of the skin. Only 
one is said to have had any anesthesia of the paralyzed 
member. In several instances soreness of the joints of the 
affected limb was a very painful symptom. Nine cases are 
said to have suffered from headache alone, 2 from pain in 
the back and 23 from both head- and backache. These 
symptoms were probably commoner than the figures indi- 
cate. There was no general tendency to impairment of the 
special senses. Two cases are said to have had double vision, 
3 strabismus, one was blind and one deaf. 

Initial Paralysis. — The paralysis which was the leading 
and most common characteristic of this series of cases, oc- 
curred in 119 instances. Of the remaining 13, 7 died before 
paralysis had time to develop, or it could not be determined 
whether there was really paralysis or not, and the remain- 
ing 6 that had no paralysis, all had a group of symptoms 
very common in the initial stage in those which were para- 



30 INFANTILE PARALYSIS IN VERMONT 

lyzed, such as headache, fever, convulsions or nausea, one 
or all. In those cases in which the exact day of the paralysis 
is noted, it is stated to have occurred four times on the first 
day, eight times on the second, ten times on the third, five 
times on the fourth, three times on the fifth, once on the 
sixth, four times on the seventh, and once on the tenth day 
of illness. It is quite likely that the actual duration of the 
premonitory symptoms prior to the appearance of the pa- 
ralysis was often overestimated, since loss of power in the 
extremities, especially in children, might easily go unno- 
ticed for some time, unless the physician or friends were 
looking for it. In several instances the loss of power in the 
legs was the first symptom noticed. The initial paralysis 
was located as follows: 

Both legs 69 cases 

Arm and leg, same side 10 " 

One arm 5 " 

One leg 7 " 

Both legs and one arm 4 " 

Tongue and throat 2 " 

Both arms 3 " 

All the extremities 4 " 

Extensors of one thigh 2 " 

"Variously in the arms and legs" 8 " 

External rectus of one eye 1 " 

One side of the face . .' 1 " 

One arm and the opposite leg 1 

All the extremities and abdominal muscles 2 " 

Stated to have had no paralysis 6 " 

Not determined 7 " 

Of the six cases that are said to have had "no paralysis" 
all had distinct nervous symptoms explainable only on the 
supposition that they belonged to this epidemic. All the 
seven cases in which it was not certain whether they were 
paralyzed, died early, often with convulsions, and their oc- 
currence at this time seems to warrant their being included 
in this series. 

Of those cases that are known to have fully recovered ac- 
cording to the latest information I can obtain — 



NOTES OF AN EPIDEMIC 31 

Both legs were paralyzed in 43 cases 

Arm and leg, on same side, in 4 

One arm in 1 

One arm and both legs in 1 

External rectus of one eye in 1 

One leg in 1 

There was no paralysis in 5 

That there have been more complete recoveries than this, 
viz., 56, is quite certain, but I have not been able to trace 
them. 

Fatal Cases. — Eighteen deaths occurred as follows: 1. 
Boy, 10 years; died within twenty-four hours with convul- 
sions. 2. Boy, 6 years; died on sixth day with convulsions. 

3. Boy, 10 months ; died on sixth day, paralyzed in both legs. 

4. Boy, 4 months; died on sixth day, all the extremities 
paralyzed. 5. Girl, 11 years; died on third day, no paralysis 
noted. 6. Girl, IV2 years; died on sixth day, no paralysis 
noted. 7. Female, 21 years ; died on thirteenth day, no fixed 
paralysis. 8. Male, 19 years; died on fifth day, both legs 
paralyzed. 9. Sex and age not stated; had paraplegia. 10. 
Male, 21 years ; died on third day, all extremities paralyzed. 
11. Sex and age not stated; died with convulsions. 12. Sex 
and age not stated ; had hemiplegia. 13. Girl, 7 years ; died 
on seventh day, all extremities paralyzed. 14. Boy, under 1 
year; no paralysis noted. 15. Boy, 4 years; died on second 
day of relapse, no paralysis of the extremities, but strabis- 
mus. 16. Male, 22 years ; died on third day, both legs para- 
lyzed. 17. Male, 38 years ; died on sixth day, both legs para- 
lyzed. 18. Girl, 11/2 years; died on fourth day. 

It will be seen that 10 deaths were among males and 5 
among females, and that the sex is not stated in three cases. 
Seven of those that died are known to have been under 6 
years, three between 6 and 14 years, while one died at 19 
years, two at 21 years, one at 22 years, and one at 38 years. 
The percentage of deaths among adults is seen to have been 
very high. 

A further analysis of the deaths shows that five of the 



32 INFANTILE PARALYSIS IN VERMONT 

cases were paralyzed in the legs, three in all the extremities, 
and one was hemiplegic. I might state that in the great ma- 
jority of fatal cases the diagnosis was meningitis. Such a 
diagnosis was usually not at all inconsistent with the clinical 
features of the disease. Deducting from the whole number 
of cases, those which are known to have terminated fatally, 
and in recovery (74 in all), there remain 58 cases to be ac- 
counted for. Just how many of these are still and probably 
permanently paralyzed, I am not able to state. It was a com- 
mon experience for a part of the initial paralysis to clear 
up within the first month, leaving a single member or a 
single group of muscles weak and wasted. Thus, many cases 
that at first seemed to be paralyzed in both legs soon im- 
proved as to one, and the permanent lesion was seen to be in 
the other limb or in a few of its muscles. The extensor mus- 
cles of the thigh, the glutei, ileopsoas, calf muscles, and an- 
terior tibial group, in the lower extremity, and the deltoid 
and extensors of the forearm, were frequent sufferers. 

Permanent Paralysis. — Of the 58 cases which my report 
left unaccounted for, I have been able to get reports of 30 
which are still maimed, from six to nine months after the 
initial attack. Of these 16 are stated to be males, and 12 fe- 
males. Eighteen are under 6 years, 7 are between 6 and 14 
years, and 5 are over 14 years of age. Here again we see the 
high percentage among the older patients. Of these 30 
cases — 



All the extremities are paralyzed in 1 case 

Both arms in 1 

Extensors of one thigh in 6 

Glutei and lower spinal muscles in 1 

Both legs in 6 

Extensors of one thigh and one leg in 2 

One leg in 6 

Glutei alone of one side in 1 

One foot and ankle in 1 

Extensors of one hand in 1 

Both legs, thigh and hips in 1 

One arm in 2 

Complete hemiplegia in 1 



NOTES OF AN EPIDEMIC 33 

The muscular atrophy in most of these cases is marked 
though combatted by the usual treatment of rubbing, mas- 
sage and electricity. 

During this epidemic and in the same geographical area, 
an acute nervous disease, paralytic in its nature, affected 
domestic animals. Horses, dogs and fowls died with these 
symptoms. 

The only reliable facts which I am able to give of the 
pathologic conditions in these cases among the lower ani- 
mals are from the examinations of the cord of a horse that 
died paralyzed in the hind legs, and from that of the cord 
and brain of a fowl which was paralyzed in its legs and 
wings. Dr. W. W. Townsend, of Rutland, who made the ex- 
amination of the horse, says that the examination of a sec- 
tion of the lumbar portion of the cord showed a "granular 
degeneration and pigmentation of the ganglion cells of the 
anterior cornua, and atrophy of the anterior nerve roots." 
He further states that there was no meningitis in this case. 
Dr. Charles L. Dana, who made the examination of the 
fowl, with the aid of Dr. Dunham of the Carnegie Labora- 
tory, found "an acute poliomyelitis of the lumbar portion 
of the cord and no meningitis." A bacteriologic examina- 
tion of the same cord by Dr. Dunham gave negative results, 
and it was found that the inoculating needle did not strike 
the diseased parts. 

It was not infrequently remarked by physicians practic- 
ing in this valley at the time of this epidemic, that the usual 
diseases of children were accompanied with exaggerated 
nervous symptoms. Headache, convulsions and delirium 
were common. 

It is recorded by Medin, in an epidemic of poliomyelitis 
which he reports, and to which I shall presently refer, that 
polyneuritis prevailed with poliomyelitis. The pain, hyper- 
esthesia, and tenderness of the extremities suggest such an 
explanation in some of our cases. Gowers is also cited by 



34 INFANTILE PARALYSIS IN VERMONT 

Putnam (American Journal of the Medical Sciences, March, 
1895), as speaking of the combined occurrence of poliomye- 
litis and neuritis. It will be readily seen that it would be 
quite impossible to reconcile the widely varying phenomena 
of this epidemic with the established characteristics of any 
one disease. So it is not strange that local observers dif- 
fered in their diagnoses. In collecting notes of this epidemic 
I did not seek any disease by name, endeavoring only to se- 
cure histories of such cases as had had well-marked symp- 
toms of acute nervous disease, the paralysis usually being 
the test symptom. Meningitis, poliomyelitis and neuritis 
were mentioned with varying frequency, and it is only a 
careful study of the epidemic as a whole, giving due weight 
to the predominating symptoms, the paralysis, of course, 
being the most striking, together with a knowledge of the 
latest pathology of these diseases, that seems to warrant 
the conclusion that the essential disease was poliomyelitis. 
Some of the commonest symptoms seen in our epidemic 
were entirely foreign to this disease as long described. Like- 
wise, too, its epidemic character and the simultaneous af- 
fectation of the lower animals. I am especially indebted to 
Dr. M. Allen Starr for notes of the latest views of the path- 
ology of poliomyelitis. 

In Zeitschrift fur Klin. Med., 1892, Goldschreider's views, 
founded on such cases as ended in autopsies, are given as 
follows : "The disease begins with a very intense congestion 
of the central arteries of the spinal cord which come up on 
each side of the central canal and spread out in the gray 
matter of the posterior horns, but the posterior horns are 
chiefly supplied with blood from the peripheral arteries, 
and hence, are less affected when the inflammation is lim- 
ited to the distribution of these central arteries. After the 
engorgement of all the arterial twigs, diapedis occurs and 
the surrounding nervous tissue is permeated by small cells 
and by serum. It is this choking of the gray matter by the 



NOTES OF AN EPIDEMIC 35 

inflammatory products which leads to the suspension of 
functional activity, and when, as in many cases, from im- 
poverished nutrition the cells of the anterior horns are ac- 
tually disintegrated by the inflammatory products, perma- 
nent destruction of the nerve tissue ensues. Goldschreider 
believes, therefore, that the primary condition is a conges- 
tion in the domain of a definite set of arteries, quite com- 
parable to the condition occurring in the lung in pneumonia 
and in the intestine in typhoid fever. 

Siemerling, in an article on the "Pathology of Infantile 
Paralysis" in Archiv filr Psychiatrie, January, 1894, says: 
"after a careful review of all the literature we reach, there- 
fore, the following conclusion, that in the pathogenesis of 
infantile paralysis the inflammatory lesion of the intersti- 
tial tissue in connection with a distension of the blood- 
vessels, especially in the region of the anterior spinal ar- 
teries, plays the chief role. A primary inflammation of the 
ganglion cells in the sense given by Charcot is not to be ad- 
mitted." 

In view of this newer pathology, showing as it does that 
the initial lesion is not confined to the anterior horns, but 
that there is a simultaneous invasion of other portions of 
the cord, the exceptional symptoms seen in our epidemic are 
rendered explainable. 

The results of autopsies made by Rissler were even more 
striking. He found an acute parenchymatous inflammation 
of the anterior horns in the cord with degeneration of the 
ganglion cells and secondary degeneration of the nerve fi- 
bers in the association tracts, in the anterior columns and 
in the anterior nerve roots; also in the nuclei of the hypo- 
glossus, vagus, facial and abducens nerves. In most of the 
cases the anterior horns were particularly affected ; in other 
cases, also the peripheral nerves and brain cortex. It was 
possible that all the nerve nuclei in the medulla and pons 
should be affected. In the light of these recent pathologic 



36 INFANTILE PARALYSIS IN VERMONT 

researches taken in connection with the most noted clinical 
features of this outbreak, viz., the season of the year, the 
preponderance of cases among children, the widely varying 
and almost universal paralysis and the low mortality, the 
conclusion seems unavoidable that the essential disease was 
poliomyelitis. Under this classification the epidemic at once 
assumes great importance in several particulars : 

1. From the simple fact that it was an epidemic of polio- 
myelitis. 

2. From the great number of cases occurring. 

3. From the simultaneous affectation of the lower ani- 
mals. 

While epidemics of poliomyelitis are not unknown or un- 
recorded, recent authorities speak only vaguely of their 
occurrence. It has not thus far found a definite place in the 
descriptions of this disease. The fact that poliomyelitis may 
occur epidemically, suggests, of course, an infectious origin, 
a view of the nature of the disease which has only been re- 
cently discussed. 

I have been able to find the following reference to out- 
breaks of poliomyelitis of epidemic character, very largely 
through the assistance of Prof. Jacobi. 

In the transactions of the Tenth International Congress 
(Berlin, 1891), Vol. ii, Prof. 0. Medin reports that Bergen- 
holtz in Sweden observed and reported thirteen cases occur- 
ring near Lyons, France, four of which were fatal. Medin 
also cites Eichhorst, who speaks of observations some- 
times made of several cases occurring in the same neighbor- 
hood. G. Lotmer (American Journal of the Medical Sci- 
ences, 1843) was told by the parents of a child treated by 
him for poliomyelitis (teething paralysis), that in a place 
where they previously lived eight or ten cases had been 
known within three or four months. Medin's epidemic, how- 
ever, is the most extensive of any of which I find a record, 



NOTES OF AN EPIDEMIC 37 

and bears in many respects a close resemblance to the Ver- 
mont epidemic. The disease appeared in Stockholm in the 
month of May, 1887, and by August 9 had assumed an epi- 
demic character. Medin saw twenty-nine cases between the 
latter date and September 23, and knew of forty-four during 
the summer from May to November. Three of his cases were 
fatal in the acute state. "There were noticed paralysis of the 
abducens in five cases, disturbance of speech in a few; in 
one case paralysis of the tongue, in several of the accessori- 
ous; in others, symptoms referable to the vagus. Disturb- 
ance of the voice and paralysis of the muscles of mastication 
and vasomotor paralysis were seen in two fatal cases. In 
one ophthalmoplegia externa. At the time of the Stockholm 
epidemic, during August and September, polineuritis ap- 
peared and was thought to be due to the same cause. This 
neuritis was followed by considerable tenderness. These 
neuritis cases, however, showed no wasting." 

It will thus be seen that Medin's observations are very 
similar to those here recorded, and together with the latest 
pathologic views of the disease, will seem to mark the neu- 
ritis of which he speaks as a varying manifestation of polio- 
myelitis. 

Putnam (Boston Medical and Surgical Journal, Vol. 
cxxix, p. 509) speaks of the unusual prevalence of polio- 
myelitis in and about Boston during the latter part of the 
summer of 1893. Twenty-six cases had come to his notice 
during that season. 

That a disease occasionally prevails epidemically suggests 
a specific poison, a definite toxin, and this phase of the eti- 
ology of poliomyelitis has recently received attention from 
foreign observers as well as from Dana, Putnam and others 
in this country. Thus far, however, there does not seem to 
have been any substantial progress made toward isolating 
any specific microorganism peculiar to this disease. 

Our epidemic with that of Medin suggests, though on 



38 INFANTILE PARALYSIS IN VERMONT 

purely clinical grounds, the possibilty of such a cause. The 
unfortunate absence of an autopsy in our cases, though 
strenuous efforts were several times made to secure them, 
prevents us from throwing any light on this part of the sub- 
ject. That domestic animals suffered with human beings in 
our epidemic is a noteworthy fact and one, so far as I can 
learn, hitherto unobserved. That such was the case cannot 
be doubted. It has long been known that animals were often 
attacked by meningitis during an outbreak of that disease in 
epidemic form. Poliomyelitis has been produced artifically 
in rabbits and guinea-pigs, but so far I have been unable to 
find an instance of its spontaneous occurrence simultane- 
ously with the disease in man. This fact again emphasizes 
the possible infectious character of the disease and lends ad- 
ditional interest to the epidemic here recorded. 



ANTERIOR POLIOMYELITIS IN VERMONT 
IN THE YEAR 1910* 

By Charles S. Caverly, M.D. 

DURING the summer of 1894 an outbreak of poliomye- 
litis occurred in the Otter Valley in this state which 
was at the time unprecedented in the number of 
cases. 

This early Vermont outbreak attracts attention by reason 
of the number of cases involved, also because of certain 
other features hitherto unnoticed in this disease. These were 
the facts that lower animals seemed to be affected, that there 
were fatal cases in the human family and that the disease 
was not confined to childhood. 

All these phases of anterior poliomyelitis have since re- 
ceived much attention, as epidemics of the disease have re- 
curred with increasing frequency. From 1894 to the present 
time this disease has increased with alarming rapidity — 
not only in this country but abroad. Many large epidemics 
have occurred and the death rate has apparently increased 
with the epidemic prevalence of the disease. 

As would be expected of a disease that is so obviously 
spreading and recurring in epidemic form, poliomyelitis is 
being studied now the world over. The features of these 
epidemics, so suggestive of an infectious cause, are the sub- 
ject of careful observation in the field and experimental re- 
search in the laboratory. Thereby a wholly new literature is 
rapidly being written into medicine. 

With the possible exception of tuberculosis, no disease is 
now exciting as much interest in medical circles as polio- 
myelitis. 

Two or three decades ago the disease received scant 



•Reprinted from Bulletin of the Vermont State Board of Health, Vol. XII, No. 2, Dec. 
1, 1911. 

39 



40 INFANTILE PARALYSIS IN VERMONT 

notice in the text books. The cases were rare — "sporadic" 
— and usually connected with the early years of childhood, 
the first dentition. Fatalities were hardly known. The after 
effects were appreciated as bad, but, fortunately, the rarity 
of the disease made these less noticeable. 

The recent intense study of poliomyelitis has not been 
without results and promises soon to solve the mysteries 
surrounding its causation and spread. 

The infectious nature of the disease had been pretty con- 
clusively shown by the work of Landsteiner and Popper, as 
well as by Flexner and Lewis. Emulsions of diseased cords 
have been used to transmit the disease in a series of mon- 
keys. 

It has been shown that the virus persists in the nasal 
mucosa for a long time. This fact suggests a possible con- 
nection with the infective principle of epidemic meningitis. 
The two diseases have other features in common. 

These experiments have also made it possible to diagnose 
abortive cases, and have shown that urotropin has an in- 
hibiting influence on the appearance of the paralysis. They 
have shown that the fly may harbor the virus for a period 
of at least forty-eight hours. 

Aside from the results of experimental research in polio- 
myelitis, the clinical study of epidemics has suggested quite 
strongly its contagiousness, directly from person to person 
and by way of third persons. 

Aside from the experimental work referred to, the dis- 
ease has been the subject of considerable study by the Health 
Departments of Massachusetts, Pennsylvania and Minne- 
sota in this country and by scientists of several European 
countries. Health officials everywhere are collecting much 
clinical data, which must eventually prove useful in this 
connection. 

In the collection of the data in regard to the outbreak in 
Vermont in 1910, and the preparation of the charts and 



ANTERIOR POLIOMYELITIS IN VERMONT 41 

tables given herewith, the author of this paper has had 
valuable assistance from Dr. B. D. Adams, inspector of the 
State Board of Health. 

The line of enquiry followed has been quite largely sug- 
gested by the published Reports of the Massachusetts State 
Board of Health on the recent outbreaks in that state. 

Since the Vermont epidemic of 1894 this state has not 
suffered from this disease in anything approaching epidemic 
form until 1910. In 1910 we had in the state sixty-nine* 
cases, of which accurate records can be secured. The actual 
number of cases was greater than this. Many physicians 
and some health officers were slow to learn that the disease 
was reportable. Hence some cases escaped official notice. 

The history of this outbreak in Vermont is interesting 
especially because of its possible relation to outbreaks in 
Massachusetts and the Province of Quebec. 

The state of Massachusetts suffered a rather extensive 
outbreak in 1910. One of the chief foci of the disease in 
that state was in the city of Springfield. In that city there 
were 130 cases.f The disease in Springfield began in May, 
increased to July, when the epidemic culminated, and de- 
creased gradually through August, September and October. 

An outbreak of the disease also occurred in the Province 
of Quebec. 

Reliable and complete data in regard to this outbreak are 
not available, but that there were a considerable number of 
cases during the summer, there is no doubt. 

The affected area in the Province of Quebec was in the 
neighborhood of Sherbrooke. The outbreak seemed to center 
about a summer resort of about 500 permanent population, 
called North Hatley. This resort is between Newport and 
Sherbrooke. It is on Massawippi Lake and has about 1500 
summer visitors, largely from this country. There is direct 



*Three additional cases have come to light since the above was written, and too late 
to tabulate in this Report. 

tAnnual Report of the Health Department, Springfield, 1910. 



42 



INFANTILE PARALYSIS IN VERMONT 



railroad communication between Orleans County in Ver- 
mont and the places affected on the other side of the border. 

The epidemic in this area began in June and increased 
until August and September. There were only four or five 
cases reported in Sherbrooke, but the resident doctor at 
North Hatley estimates that there were twelve cases in that 
resort that sustained permanent paralysis, besides a con- 
siderable number which recovered. 

The accompanying chart shows the monthly distribution 
of cases in our outbreak. 



Poliomyelitis. Vermont, 1910. Seasonal Distribution, 
vermont state board of health. 

September 
23 Cases 



August 
17 Cases 



July 
12 Cases 



October 
12 Cases 



November 
2 Cases 

I 

The only comment that seems necessary at this point is 
the fact that the disease began in Vermont two months later 
than in the Connecticut Valley in Massachusetts. The Cana- 
dian outbreak seems to have begun in June, but most of the 
cases occurred in August and September, coincident with 
the Orleans County group in Vermont. 

The distribution of the disease in the state is still more 
suggestive in connection with our neighbors north and 
south. The accompanying chart shows graphically the rela- 
tive number of cases by counties and also on the east and 



ANTERIOR POLIOMYELITIS IN VERMONT 



43 



west of the Green Mountains. It will be noted that fifty-one 
of the sixty-nine cases reported were on the east side of the 
state. A glance at the map shows the close connection that 
exists between this side of the state and the affected areas 
in both Canada and Massachusetts. 

Poliomyelitis. Vermont, 1910. 
distribution by counties east and west. 



EAST 






Washington 
Windham 














Caledonia 


mmsmam 


\ 


Essex 


None 




Orange 


None 




Total 


51 




WEST 
Rutland 






Chittenden 
Addison 






Hi 




Bennington 


■ 1 




Franklin 


Hi 




Grand Isle 


None 


" 


Lamoille 


None 




Total 


18 





20 



12 



Proportionate to the population, by far the largest num- 
ber of cases occurred in Orleans County. After this follows 
Windham, Washington and Windsor. 



Poliomyelitis. Vermont, 1910. 

distribution by counties in proportion to population. 

Orleans 1 to 1,150 

Washington 1 to 3,500 

Windham 1 to 3,400 

Windsor 1 to 4,800 

Caledonia 1 to 6,700 

Rutland 1 to 6,000 

Chittenden 1 to 6,100 

Addison 1 to 20,000 

Bennington 1 to 21,000 

Franklin 1 to 29,000 




,|i L^-f *m 

•- i. . fe "Sf jfcS i- . 

I :&J j'^r L ':M 5 



Distribution of 

Poliomyelitis 

in 

Vermont 

1910 



f^F/ *--** „.a ./J*> 1< 

'» j^'"':*"'! / •' / :'" Ig 



f 



ANTERIOR POLIOMYELITIS IN VERMONT 45 

Orleans County at the north end of the state is in close 
connection with the territory affected with the disease in 
Canada; and Windham, particularly, is almost as closely 
connected with Springfield in Massachusetts. As to the 
traceable connection by means of cases between our state 
and our neighbors, mention will be made later. 

The map here shown gives a graphic picture of the geo- 
graphical distribution of the Vermont outbreak in 1910. 

The following charts show the division of the cases by 
sex and age. 

Poliomyelitis. Vermont, 1910. 

SEX 

Male 9BBHSHGBHfflBBHHH^^H9BBBII^HKH8B^BBQSI^BBBIi40 

Female BHHHIB&IUHidUHEMMHnHiEiHHHiaKRE 29 



Poliomyelitis. Vermont, 1910. 
division of cases according to age. 




Under 5 — i"MWiM^^^^— i^wmim^m 

10 to 20 nrmiTMiirffiiiriitfit^iiiTg 13 

5 to 10 

20 to 30 
30 to 40 

40 to 50 mm 2 

An interesting fact developed by the chart for age is that 
a little over 20 per cent of the cases were over twenty years 
of age. In this connection it should be stated that the aver- 
age age of all cases was ten years and six months. The aver- 
age age of all those who had some degree of permanent 
paralysis was a little under ten years. The average age of 
those who died was thirteen years and four months ; and of 
those that fully recovered nineteen years and ten months. 



46 INFANTILE PARALYSIS IN VERMONT 

The nationalities affected were: 

American 47 

French Canadian 6 

Irish 3 

English 2 

Polish 2 

Russian 2 

Not stated 7 

In regard to the surroundings of the patient, the follow- 
ing statistics have been secured : 

Age of House 

Under ten years 10 

Over ten years 56 

Not stated 3 

Detached House or Tenement House 

Detached house 43 

Tenement house 15 

Not stated 11 

Soil About the House 
Dry 43 Wet 26 Not stated 2 

Surroundings of the Patient's House 

Steam railway within fifty rods 14 

Street railway on the street 5 

Stream or pond within fifty rods 37 

Manufacturing establishment within fifty rods 10 

Domestic Animals Kept 
Reported as keeping cats, dogs, hens, cows, horses and pigs: 
42 kept cats. 12 kept cows. 

31 kept dogs. 13 kept hens. 

12 kept horses. 7 kept pigs. 

Proximity of Animal Quarters 

Animal quarters within 20 feet of house 16 

Animal quarters at greater distance 28 

Not stated 25 

An effort was made to secure reliable figures as to the 
presence of parasites or vermin in the houses affected. The 
observation of the inspector and the answers to questions 
which he was able to secure were so obviously unreliable 
that the figures are considered worthless. It may, however, 



ANTERIOR POLIOMYELITIS IN VERMONT 47 

in a general way be stated that the disease was quite apt to 
occur in houses that obviously harbored vermin of various 
sorts. 



Water Supply 

The water supply of infected houses was usually good. The exact 
figures are as follows: 

Wells 6 

Private aqueduct 1 

Public supply 11 

Stated as good 23 

Stated as fair 7 

Spring water 21 

Sewer Facilities 
The sewer facilities were probably on an average poor. They are 
stated as: 

"Dry closet" 44 

Connected with the public sewer 23 

Not stated 2 

Cases Located in Railroad Towns 

Number of cases that occurred in a town located on a railroad . . 58 
Number of cases that occurred in towns off the railroad 11 

Family History 

Good (no case of chronic disease, like tuberculosis, cancer, dia- 
betes, Bright's disease, or rheumatism in immediate family) 53 

Fair (one case of such disease only in immediate family) 11 

Bad (two or more such cases in immediate family) 5 

Health a Month Prior to Attack 

Gastro-intestinal disorder 6 

Coryza 2 

Bronchitis 1 

Whooping cough 2 

Tonsillitis 1 

Not well — no definite disease 5 

Not stated 1 

Good 51 

In this connection it is proper to give the incidence of other dis- 
eases in the same town: 

In towns where whooping cough prevailed there were 8 cases. 

In towns where the grippe prevailed there were 3 cases. 

In towns where mumps prevailed there were 4 cases. 

In towns where scarlet fever prevailed there were 4 cases. 

In towns where paratyphoid prevailed there were 9 cases. 

In towns where diphtheria prevailed there were 2 cases. 

In towns where typhoid fever prevailed there were 4 cases. 

In towns where chicken pox prevailed there was 1 case. 



48 INFANTILE PARALYSIS IN VERMONT 

In regard to school attendance, our outbreak began and 
reached its crisis during the summer vacation. Only four 
cases are reported as having attended school within one 
month. 

Seventeen cases had been away from home within the 
month. Of these, nine had been in towns or cities where the 
disease was present, although it was not known in any of 
these cases that the person had been in contact with the dis- 
ease. Eight cases gave a history of having been in direct 
contact with other cases. Two others came in contact in- 
directly. Five others had possibly been in contact directly 
or indirectly. 

One patient, who died, twenty-seven years old, from Brat- 
tleboro, visited in Springfield, Mass., within a fortnight of 
his attack. This case occurred September 20, rather late in 
the epidemic. 

The earliest date of any of the Brattleboro group of cases 
that have been secured was July 16. This was a case in 
Brookline that had not been out of town within a month. 

Another case in Irasburg, twenty-two years old, attended 
the fair in Sherbrooke, Canada, two weeks before attack. 
This case, also fatal, occurred September 16, also rather late 
in the epidemic. 

Of the early cases in the Orleans County group, one small 
child was brought from Topsfield, Mass., about thirty days 
before illness began. No other early case can be traced to 
another state. 

The obvious possibility of mild unrecognized "abortive" 
cases, occurring in connection with the outbreak, makes any 
attempt to trace connection between centers of infection 
very difficult and, in the present state of our knowledge of 
the etiology of the disease, almost entirely speculative. 

While none of the earlier cases in Vermont are directly 
traceable to visits to neighboring centers of infection, the 
coincidence of the outbreaks in time and the direct railroad 



ANTERIOR POLIOMYELITIS IN VERMONT 49 

communication with these other centers must still remain 
suggestive of a common source. 

There were three instances of two cases in the same fam- 
ily. In one other instance a case occurred in the same family 
ten years ago. In still another instance, the case was a 
nurse, who was caring for a case of poliomyelitis. 

Ten cases had been in the water within a week of the at- 
tack. 

Six had been exposed to extreme heat. 

Five had been chilled. 

Six patients gave a history of recent injury — usually a 
fall with blow on the head. 

First Symptoms Noted 

Fever 69 cases 

Pain 45 cases 

Tenderness 42 cases 

Vomiting 38 cases 

Diarrhoea 10 cases 

Headache 19 cases 

Head cold 14 cases 

Delirium 10 cases 

Chills 14 cases 

Sore throat 9 cases 

Symptoms During Attack 

Disturbance of digestion occurred in ... . 63 cases 

Bladder symptoms occurred in 22 cases 

These symptoms were retention 17 cases 

Incontinence 4 cases 

Frequent urination 1 case 

Pain and tenderness was a prominent symptom, occurring in sixty 
cases, at some time during the attack. 

The pain was general in 14 cases 

The pain was in the extremities in 28 cases 

The pain was in neck and back in 18 cases 

The accompanying chart shows the incidence of the 
paralysis. 

Poliomyelitis. Vermont, 1910. 
day of disease paralysis occurred. 

HHHHH9HH 11 
After 7 VMWmiM 4 

Not stated flHHBHnH 8 



50 INFANTILE PARALYSIS IN VERMONT 

It should be stated that the paralysis appeared simultane- 
ously with the febrile symptoms or was the first symptom 
noted in eight cases. 

The distribution of the paralysis is shown by the follow- 
ing chart: 



Poliomyelitis. Vermont, 1910. 
distribution op paralysis in the individual. 

Legs ■■■■■■■■■■■^^^■■■■■■■■■■■HnnBH 13 

Right Leg BBHHIBHHBBHII^BDBBHBnBH^HBflHBS! 10 
Left Leg I^^BHHHBIHB9HHHHMflHHMHHHa 10 

1 Leg (not wuaumm<mmmmmMmimmiHKB& <; 
stated) ^^m^^^^^^^^mmi J 

Arm and Leg 
Same side 

Arm and Leg 
Opposite side 

Both Legs 
1 Arm 

Right Arm 

Left Arm 

All extrem- 
ities 

Right Hand 1 
Squint 1 

The condition of the cases six to nine months after the 
attack is shown by the following chart : 



Poliomyelitis. Vermont, 1910. 
condition of cases six to nine months after attack and deaths. 

Fully ryawmm 5 

recovered i^^^^^ 

Some degree ■gHZHnSRnHlKBH&i^HSBBI^BHBEHSffiGHKSDIIHBBEHBH 54 
of paralysis ^^^^^^^^^^™^^^^^^^^^^^^^^^^^^^^^™ 

Died HHBBramn 10 

The death rate of poliomyelitis has been variously stated 
by late investigators at from 8 to 15 per cent. 




ANTERIOR POLIOMYELITIS IN VERMONT 51 

The death rate among our cases in 1910 by age periods 
was as follows : 

Of 32 cases under five years, 4 died, or 12+%. 
Of 8 cases between 5 and 10 years, died, or 0%. 
Of 13 cases between 12 and 20 years, 3 died, or 23 + %. 
Of 8 cases between 20 and 30 years, 2 died, or 25%. 
Of 5 cases between 30 and 40, died, or 0%. 
Of 2 cases between 40 and 50, 1 died, or 50%. 

While the mortality in our outbreak was 14.49 per cent 
among all ages, the mortality among those under ten years 
was 10 per cent. Among those over ten years, it was 21.42 
per cent. This mortality is rather higher than in some re- 
cent reports. These figures would probably be reduced if we 
had been able to secure fuller reports of the mild or abortive 
cases in this outbreak. The mortality figures, however, cor- 
roborate the findings of other observers, viz., that the death 
rate is higher in older subjects. 

The investigation of the foregoing outbreak of poliomye- 
litis revealed two rather significant instances of paralytic 
disease in the lower animals. 

One of these instances was the occurrence of a form of 
paralytic disease in calves. In the language of the owner, 
an exceptionally observing and intelligent man, he had a 
herd of eighteen calves, pastured on an interval meadow 
about September 1. They were provided with good water. 
There were no swampy places and no sewage reached the 
river, which flowed through the meadow. These calves were 
seven months old. The average weight was about three hun- 
dred pounds. 

About the first of September, one was noticed not to take 
his feed and it soon became paralyzed in the hind legs and in 
less than twenty-four hours died. When the carcass was 
being drawn away, the other calves gathered about. There 
was some frothy substance expelled from the nostrils of the 
dead calf. The owner noticed that one of the other calves 
put its nose to the nose of the dead calf "in a smelling way" 



52 INFANTILE PARALYSIS IN VERMONT 

and near enough to get some of the froth upon its own nose, 
whereupon he remarked that if this is a contagious disease, 
he was fearful the other calf might acquire it. This other 
calf was marked for identification. In less than twenty-four 
hours that calf was paralyzed behind the same as the other 
and very soon it died. In this manner five calves, one after 
another, of this herd, died — all within ten days. No veteri- 
nary saw them. 

The farmer made what he terms "an unprofessional ex- 
amination" of the carcass of the second calf that died, and 
states that there was no discoloration of the tongue, neck, 
legs or lungs. He thought the lungs appeared to be normal 
and he found only about two teaspoonfuls of liquid in the 
chest cavity. The pleura was not inflamed and the bowels 
appeared to be normal. 

I quote this layman's description of the disease in his herd, 
as stated, because it is that of a disinterested and rather 
accurate lay observer and because some two to three weeks 
later a young man, twenty years old, living in a house some 
fifteen to twenty rods from the pasture where these calves 
ran, was taken sick with poliomyelitis with resulting paraly- 
sis of the lower extremities. 

The other instance of the disease in lower animals, to 
which I referred, occurred at a farm in the town of Essex 
where there were two cases of the disease in the same family. 

To quote the language of Dr. C. M. Ferrin, health officer : 

"The father of these two boys bought some pigs from a 
party who had, as it transpired, pigs in his herd that had 
some paralytic disease of the hind legs. The pigs which this 
father bought developed a similar paralysis and were fed 
and cared for by the boys. Within two or three weeks from 
the time these pigs became affected the boys were taken 
sick." 

These boys, one after the other, had poliomyelitis, being 
taken sick two days apart. 



ANTERIOR POLIOMYELITIS IN VERMONT 53 

It is of course regrettable that neither of these instances 
of disease in the lower animals was discovered in time to 
have adequate pathological or bacteriological examinations 
made. They emphasize, however, the facts : that the disease 
affects lower animals, that it occurs in connection with the 
disease in the human family, and that there are good prima 
facie reasons for thinking there may be a common cause 
for cases in man and the lower animals, and that it may be 
communicated from animals to man and vice versa. 

The year 1910 was not a dry year. 

The precipitation data for Vermont in 1910 compared 
with the means as observed at the Weather Bureau Station 
at Burlington are as follows : 





April 


May 


June 


July 


August 


Sept. 


Annual 


Means, 


1.98 


3.01 


3.34 


4.14 


3.60 


3.56 


32.68 


1910 


2.10 


3.42 


3.10 


3.06 


2.76 


2.76 


31.63 



It will be observed from these figures that while the pre- 
cipitation for the early summer months was somewhat be- 
low the means for this state, that the difference was not 
very marked. I may remind you, in this connection, that the 
precipitation for the year 1894, in which the epidemic pre- 
viously referred to occurred, in Rutland County, was only 
22.96, which is, with one or two exceptions, the least ever 
reported in the state. The annual precipitation for the year 
1909 was 35.76; and for the year 1908, 23.49, the latter 
being also extraordinarily low. The year 1910, however, was 
not an exceptional year as far as the precipitation records 
show. 

In conclusion, I wish to call attention to certain facts, 
bearing on the prevention of this disease. 

First, "infantile paralysis" and "acute poliomyelitis" are 
perhaps more properly "epidemic poliomyelitis." 

Second, the disease is infectious, and, to a certain extent, 
contagious. It can probably be transmitted by third persons 
and possibly inanimate objects, as well as by the sick. It 
seems to be equally a disease of man and animals. 



54 INFANTILE PARALYSIS IN VERMONT 

Third, it apparently spreads from epidemic centers in the 
direction of the greatest travel. 

Fourth, the discharges from the air passages, kidneys and 
bowels are all to be viewed with suspicion as possibly infec- 
tious. 

Fifth, this disease may affect adults. 

Sixth, it is a disease that is dangerous to life, as well as 
disastrous in its after effects on those who survive. 

Inasmuch as there are various grades of severity of the 
disease, which we recognize by the paralysis, there are un- 
doubtedly mild abortive cases. It is impossible except with 
laboratory facilities for animal experimentation at the pres- 
ent time to diagnose these abortive cases with any certainty. 
Febrile and grippy cases with vague nervous symptoms of 
any description occurring in a neighborhood where there 
are cases of poliomyelitis, should be treated by health offi- 
cials as cases of that disease. 

Health officials and physicians should be on the alert dur- 
ing the summer months to recognize this disease as early as 
possible. They should report any suspicious paralytic dis- 
ease in any of the lower animals to the State Board of 
Health. Every scrap of information bearing on this dis- 
ease in man, as well as the lower animals, should be care- 
fully gathered and sifted in order that every community 
may contribute as much as possible to the solution of the 
cause of this increasingly prevalent infection. 

Perhaps I cannot do better than to quote from the circular 
recently issued by the American Orthopedic Association and 
the American Pediatric Society and addressed to health 
authorities and boards of health : 

"All cases of infantile paralysis should be stictly quaran- 
tined, sputum, urine and feces being disinfected, the same 
rigid precautions being adopted as in scarlet fever. This 
quarantine should, in the opinion of the committee, last for 
four weeks in the absence of definite knowledge as to when 
the infection ends. Children from infected families should 



ANTERIOR POLIOMYELITIS IN VERMONT 55 

not be allowed to go to school until the quarantine is aban- 
doned. The transportation or transfer of acute cases in pub- 
lic conveyances should be strictly forbidden. It would be 
very desirable to adopt provisional quarantine measures in 
suspicious cases in a community where an epidemic prevails. 
The report of all cases of infantile paralysis to the public 
health authorities should be enforced by law, and all deaths 
from this cause should be properly described and regis- 
tered. A careful study of epidemics by public authorities is 
strongly advised." 

To the health officers of Vermont let me say: Let every 
physician learn from you that this disease is reportable. 
Enforce the laws as to reporting diseases that are "infec- 
tious and dangerous to the public health" as regards polio- 
myelitis. Enforce the "full quarantine" in this disease. Dis- 
infect and clean up after the acute stage is passed, as you 
would after diphtheria. 



ANTERIOR POLIOMYELITIS IN VERMONT 

IN 1911* 

By Charles S. Caverly, M.D. 

IT may be recalled that Vermont suffered a rather marked 
outbreak of epidemic poliomyelitis during the year 1910 ; 
it should be further noted that the 1910 outbreak af- 
fected chiefly the Connecticut and tributary valleys, and 
that the brunt of the epidemic was felt chiefly about Brat- 
tleboro, Windsor, Montpelier, Barton and Irasburg. In these 
regions occurred fifty-two of the seventy-two cases which 
were recorded in the state. This number includes three 
cases, records of which were received too late for tabula- 
tion in the Report for 1910. 

Of the twenty cases occurring on the western side of the 
state, the chief centers were Rutland and Burlington. 

Records of twenty-seven cases have been obtained for the 
year 1911. 

The disease in 1911 was distributed throughout the year, 
beginning in March. The hottest months show, as usual, the 
largest number of cases, but there is not the preponderance 
that is the rule. 

Poliomyelitis. Vermont, 1911. Seasonal Distribution, 
vermont state board of health. 

Aug. 
6 cases 

July 
4 cases 
June aa Sept. Oct. 

3 cases \ 3 cases 3 cases 

May n a jm Nov. Dec. 

2 cases 2 cases 2 cases 

Mar. April m r m 

1 case 1 case ! | I 

■ ■II I I I I I I 

*Reprinted from Bulletin of the Vermont State Board of Healthy Vol. XII, No. 3, Mar. 
1, 1912. 

56 



ANTERIOR POLIOMYELITIS IN VERMONT 57 

Reference will be made presently to the relation which the 
disease bore to temperature and precipitation. 

The geographical distribution of the disease in 1911 in 
Vermont is interesting. The following chart shows the dis- 
tribution by counties : 

Distribution by Counties East and West. 
East West 



Orleans 





Rutland 


16 


Washington l^f 


Chittenden 





Windham 





Addison 


31 


Windsor 


3hb 


Lamoille 





Caledonia 


IB 


Bennington 


2 


Essex 





Franklin 


11 


Orange 





Grand Isle 






Total 5 Total 22 

A comparison of the geographical distribution of the dis- 
ease in 1910 with that of 1911 shows that the eastern and 
western sides of the Green Mountains have changed places. 
In 1910, 72 per cent of the cases were on the eastern side of 
the mountains, while in 1911 over 81 per cent of the cases 
were on the western. 

Orleans County, which had the largest share of the 1910 
cases, had none in 1911, while Washington, Windham and 
Windsor Counties, which were conspicuous counties in 1910, 
had in 1911 only four cases. 

On the western slope (Champlain Valley), the chief cen- 
ters in 1910 were Rutland and Burlington. In 1911 there 
were no cases in the Burlington district, while the severity 
of the outbreak was confined quite closely to Rutland. 

In this connection it must be remembered that the great 
outbreak of 1894 (the first large outbreak of this disease re- 
corded) was in the valley of the Otter Creek. In 1910, fifteen 
of the twenty-two cases occurring in Western Vermont oc- 
curred in this valley. 



58 INFANTILE PARALYSIS IN VERMONT 

An analysis of the population, physical characteristics, 
general sanitation and industries of the Otter Creek Valley 
is interesting in this connection. The portion of the valley 
affected is that just about the river in the towns of Rutland, 
Proctor and Pittsford. 

The population is cosmopolitan. The industry is marble 
quarrying and manufacture. The river carries the sewage 
of the towns, is sluggish, except when broken by the falls 
at Center Rutland and Proctor. The rock formation is, of 
course, limestone. At Proctor, the focus of the 1911 out- 
break, the population is probably more cosmopolitan than 
elsewhere in the state; this population is generally well 
housed, and the general sanitation is excellent. As compared 
with West Rutland, in which also marble is the chief and 
only industry, the general sanitary conditions in Proctor are 
superior and the quarrying population better housed. Yet 
there was only one case in West Rutland and that at a point 
remote from the quarries and mills. The chief obvious dif- 
ference in the two towns is the fact that Proctor is in the 
Otter Creek Valley, while West Rutland is not. 

In the absence of exact knowledge of the infecting or- 
ganism of poliomyelitis and its methods of spreading, any 
deductions from the above facts are perhaps superfluous. 
We may theorize to the extent of guessing that the stream 
(Otter Creek) has something to do, directly or indirectly, 
with the spread of the disease. 

The towns affected in 1911 were as follows : 



Towns Having Disease 

Cavendish 1 case. 

Pawlet 1 case. 

Proctor 9 cases. 

Pittsford 2 cases. 

Rutland 3 cases. 

West Rutland 1 case. 

Enosburg 1 case. 

West Burke 1 case. 

Middlebury 1 case. 

Vergennes 1 case. 



ANTERIOR POLIOMYELITIS IN VERMONT 59 

Weybridge 1 case. 

Manchester 2 cases. 

Cabot 1 case. 

Norwich 1 case. 

Hartford 1 case. 

Total 27 cases. 

The distribution of the disease in proportion to the popu- 
lation is shown by reference to the table following : 

East 

Washington 1 to 41,702 

Windsor 1 to 11,229 

Caledonia 1 to 26,031 

West 

Rutland 1 to 3,009 

Addison 1 to 6,670 

Bennington 1 to 10,689 

Franklin 1 to 29,866 

The map herewith attached will give a graphic picture of 
the geographical distribution of the disease in the state. 

The two following charts show the age and sex of the 
cases. 



Division op Cases by Sex. 



Male 18 

Female 9 



Division op Cases According to Age. 

Under 5 BJHWaw—WWUHB I IBII I IH 12 

5 to 10 wmmm4 
10 to 20 wwammumum 8 
20 to 30 am 2 

30 to 40 B 1 
40 to SO None 

The usual preponderance of the male sex is emphasized 
this year, 66 per cent of the cases being male. 

Age: Under 5 years, 12 cases or 44 per cent approximately. 

Between 5 and 10 years, 4 cases or 14 per cent approximately. 
Between 10 and 20 years, 8 cases or 29 per cent approximately. 
Over 20 years, 3 cases or 11 per cent approximately. 



I I » * 1 I : MaA-AjtufJ frOMTO 









W?Ai.0e/rS 






'"?4T<o/rco*0\ 






Epidemic Poliomyelitis 
Vermont, 1911 



Vermont State Board 
of Health 



I *& — !*«*ir "av f- , 






r 



ANTERIOR POLIOMYELITIS IN VERMONT 61 

The figures for this outbreak as to age limits show a pre- 
ponderance of cases under 10 years, but not as great as is 
usually the case. 

The average age of all these cases was 10 years and 7 
months; the average age of those who died was 11 years, 
and of those who survived, 9 years, 11 months. 

The nationalities affected were: 

American 16 

Anglo-Saxon 1 

Canadian 1 

Hungarian 2 

French 2 

Swedish 2 

Scotch 1 

Not stated 2 

Total 27 

Other facts about the surroundings of the patients are as 
follows : 



Age of House 

Under 10 years 3 

Over ten years 22 

Not stated 2 

Detached House or Tenement House 

Detached house 15 

Tenement house 7 

Not stated 5 

Soil About the House 

Dry 17 

Wet 6 

Not stated 4 

Proximity of Possible Influences 

Steam railway within 50 rods 7 

Street railway on street 7 

Stream or pond within 50 rods 15 

Manufacturing establishment within 50 rods . . 8 

Domestic animals, especially cats, horses and hens, were 
generally either kept by patients' families or were kept in 
the immediate neighborhood. There were no authenticated 
instances of coincident paralytic disease in any domestic 



62 INFANTILE PARALYSIS IN VERMONT 

animals this year. It may be stated, however, that a hen 
paralyzed in its legs and one wing, furnished by Dr. G. G. 
Marshall of Rutland, July 26, was examined pathologically 
by Dr. B. H. Stone, director of the Laboratory of Hygiene, 
with negative results. 

There were no recognized cases in the human family, 
however, within a half mile at least of the place where this 
hen sickened and the earliest Rutland case was August 24. 

Some attempt was made to secure facts about the pres- 
ence of vermin in the affected houses and the general sani- 
tary conditions within and in their immediate vicinity. 
Nothing of an exact or reliable nature was secured along 
these lines. It is, however, a safe statement, based on gen- 
eral observation, that the sanitary conditions (cleanliness) 
of many of the infected premises were poor. There were, 
however, notable exceptions to this rule. 



Water Supply 

Well 2 

Public aqueduct 14 

Spring 9 

Not stated .' 2 

Total 27 

In this connection it may be stated that the water supply 
of Proctor is a mountain stream, the intake being about 
seven miles from the village. The affected families in that 
village all received this supply. 



Sewer Facilities 

Public sewer 17 

Dry closet 4 

Private sewer 3 

Not stated 3 



Cases Located in Railroad Towns 
Number of cases that occurred in a town located on a railroad . . 24 
Number of cases that occurred in towns off the railroad 3 



ANTERIOR POLIOMYELITIS IN VERMONT 63 

Family History 

Good (No case of chronic disease, like tuberculosis, cancer, dia- 
betes, Bright's disease or rheumatism in immediate family.) 19 

Fair (One case of such disease only in immediate family.) 5 

Bad (Two or more such cases in immediate family.) 1 

Not stated 2 



Assigned Causes 
Among the assigned causes by attending physicians might 

be mentioned : a boy of 12 years, who was attacked imme- 
diately after attending a circus and drinking freely of so- 
called "birch beer and circus lemonade." 

Another, too, a boy of 16, who worked in a hot dry-house 
and who was obliged to go into the cold November air fre- 
quently to carry lumber in connection with his work. 

Several of the cases, as is usual under these circum- 
stances, had been accustomed "to go in swimming" during 
the hot weather. 

Eight of the cases are known to have had large tonsils or 
adenoids or both. 

Information was sought as to the number of cases that 
had been away from home within a month and only seven 
such cases were found. None of these, however, had been, 
as far as could be ascertained, where there had been cases 
of poliomyelitis. 



Prevailing Diseases in Town During Year 

In towns where diphtheria prevailed there were 7 cases. 

In towns where measles prevailed there were 4 cases. 

In towns where scarlet fever prevailed there were 3 cases. 

In towns where chicken pox prevailed there were 3 cases. 

In towns where whooping cough prevailed there was 1 case. 

In towns where smallpox prevailed there was 1 case. 

In towns where no disease prevailed there were 7 cases. 



The early symptoms noted were as follows : 

Early Symptoms Noted 

Fever in 23 cases. 

Headache in 12 cases. 

Pain in 17 cases. 



64 INFANTILE PARALYSIS IN VERMONT 

Tenderness in 11 cases. 

Vomiting in 10 cases. 

Constipation in 9 cases. 

Twitching in 8 cases. 

Delirium in 6 cases. 

Chills in 5 cases. 

Diarrhoea in 3 cases. 

Head cold in 3 cases. 

Convulsions in 2 cases. 

The symptoms during the attack are shown in the follow- 
ing table : 

Symptoms During Attack 

Disturbances of digestion in 22 cases. 

Disturbances of bladder in 13 cases. 

(7 of the 13 retention.) 

Pain and tenderness in 13 cases. 

Pain general in 6 cases. 

Pain in extremities 7 cases. 

Pain in neck and back 4 cases. 

The day in which the paralysis appeared was as follows : 
Day of Disease Paralysis Occurred 

1 to 3 days Wm^mwmwmwmwmwmwmi 16 

3 to 7 days ■■■■■ 5 

After 7 days ■ 1 

Not stated HBBMBi 5 

The distribution of the paralysis in the non-fatal cases 
was as follows: 





Both legs 




Mil Mil Ml 5 








One leg 




■HHWMItW 5 








One arm 




mam 3 








Both legs and one 


arm 


H2 




- .. 




Arm and leg (same 


side' 


) Ml 




*i 




Both arms 




■ 1 




♦ 




One side of face 




■ 1 








All extremities 




■ 1 






The initial paralysis in the fatal 


cases is 


shown 


in the f ol- 


lowing chart: 


Both legs 

One leg 

All extremities 




■BBD3 

■ 1 

■ 1 








Arm and leg (same : 


side) 


■ 1 








One arm 




■ 1 








No data obtainable 




■ 1 







ANTERIOR POLIOMYELITIS IN VERMONT 65 

Summary of conditions of cases 6 to 9 months after at- 
tack: 

Condition of Cases Six to Nine Months after Attack 

Fully recovered ■■■■■■ 5 

Some degree of paralysis i^^^MBHBBBBHBBHBH 13 

Died Banm 8 

A striking fact about this year's outbreak is its high mor- 
tality. The highest mortality which any recent figures show, 
as far as I have observed, is that in Pennsylvania in 1910.* 
In a series of 1076 cases the mortality was 22 per cent. The 
common figures for mortality in this disease are about 8 to 
12 per cent. 

The disease was of a very virulent type in 1911. Twenty- 
nine per cent of the cases recorded were fatal. The distribu- 
tion of the fatal cases is interesting. They were distributed 
as follows : 

Rutland 2 

Manchester 1 

Vergennes 1 

Enosburg Falls 1 

Cabot 1 

Cavendish 1 

Burke 1 

It will be noted that there were no deaths in Proctor, 
where there were one-third of all the cases in the state. The 
so-called sporadic (or scattered) cases seem to have been 
generally fatal. 

The mortality in the state last year was 14 per cent. This 
year (1911) it is twice as great. 

A further analysis of the fatalities from poliomyelitis in 
Vermont in 1911 recalls an interesting fact regarding the 
possible seasonal influence on the virulence of the infection, 
viz. all the fatalities during that year occurred in the colder 
months. 



*Drs. Dixon, Karsner, "Epidemiologic and Etiologic Studies of Acute Poliomyelitis 
in Pennsylvania." 



66 INFANTILE PARALYSIS IN VERMONT 

In March there was 1 case with 1 death. 
In April there was 1 case with death. 
In May there were 2 cases with death. 
Irt June there were 3 cases with death. 
In July there were 4 cases with death. 
In August there were 6 cases with death. 
In September there were 3 cases with 1 death. 
In October there were 3 cases with 2 deaths. 
In November there were 2 cases with 2 deaths. 
In December there were 2 cases with 2 deaths. 

Total, 27 cases with 8 deaths. 

No deaths were recorded during the hottest summer 
months, when most of the cases occurred. 

The mortality during this year by age periods was as fol- 
lows: 

Of 12 cases under 5 years 2 died or 17 per cent. 

Of 4 cases from 5 to 10 years 2 died or 50 per cent. 

Of 8 cases from 10 to 20 years 2 died or 25 per cent. 

Of 2 cases from 20 to 30 years 1 died or 50 per cent. 

Of 1 case from 30 to 40 years 1 died or 100 per cent. 



29.6 per cent of reported cases died. 



Referring to these reports, as regards the records of pos- 
sible connection of one case of the disease with another, one 
interesting case of this kind should be mentioned. 

A young man employed in a postoffice (cancelling stamps) 
was attacked in September. His place, after an interval of 
about one week, was taken by another young man. This lat- 
ter worked only a week at the same work as the former. In 
less than a week after he had given up this work he was 
taken sick with this disease and died in about three days. 

These boys had no special association before or after 
their employment in the postoffice and there were no other 
cases in the town. 

The postoffice where they successively worked is a new 
building. The room was not kept clean, and there was con- 
siderable dust in the air. A water closet opening into this 
room was quite filthy, due to careless use. 



ANTERIOR POLIOMYELITIS IN VERMONT 67 

Monthly Temperature, 1911. 
burlington weather station. 

Mean Normal 

March 24.0 27.3 

April 40.2 40.7 

May 62.5 53.9 

June 62.8 63.8 

July 72.5 68.2 

August 68.4 66.1 

September 56.4 58.9 

October 46.7 46.9 

November 34.0 33.7 

December 31.0 22.5 

These temperature records show that May and December 
were much above the normal mean. July was also a hot 
month. The mean for the year (44.4) was 1.4 degrees higher 
than normal. 

Precipitation 
The precipitation records of the Weather Bureau for Ver- 
mont show a general deficiency for the year 1911. 
By months they are : 

Amount Normal 

March 2.44 1.83 

April 0.83 1.87 

May 1.13 2.83 

June 2.54 3.26 

July 2.47 3.78 

August 3.83 4.01 

September 3.46 3.35 

October 2.84 3.16 

November 1.56 2.58 

December 2.51 1.69 

Year 26.52 31.56 

These figures show a dry summer. Corresponding figures 
for five years are : 

Amount 

1907 29.67 

1908 23.49 

1909 35.76 

1910 31.63 

1911 26.32 

No decided advance has been made, during the past year, 
in our knowledge of the exact cause of poliomyelitis or of 
methods of treating or preventing it. 



68 INFANTILE PARALYSIS IN VERMONT 

Flexner and Clark have confirmed, by recent animal ex- 
periments, the fact that the virus is present in the tonsils 
and pharyngeal mucosa of human beings who succumb to 
the disease. 

Hence the care that should be constantly exercised in 
cleansing the naso-pharynx in cases of the disease and in 
destroying all discharges from nose and throat. 

Health officers and physicians should always remember 
that the disease is contagious and quarantinable. 

In the summer, and especially during the presence of 
known cases in a community, physicians should be alert to 
the possibility of "abortive" cases. Children and young 
adults who present "grippy" or "rheumatic" symptoms, or 
who have any vague febrile attack should be regarded with 
suspicion. 

To the physicians of the state who have aided in securing 
the data herewith presented, our thanks are due. 

The same investigations will be pursued during 1912. 



EPIDEMIC POLIOMYELITIS 
(INFANTILE PARALYSIS) IN VERMONT* 

By Charles S. Caverly, M.D. 

PURSUING the plan undertaken, when poliomyelitis 
again appeared in epidemic form in Vermont in 1910, 
the State Board of Health has collected during the last 
biennial period such data as were available in regard to this 
growingly important disease. Dr. H. A. Ladd, the Inspector 
of this Board, has collected most of the data on which the 
reports for these years are based. These reports deal with 
the years 1912 and 1913, and continue the reports of the 
years 1910 and 1911, published in the last biennial report 
of the State Board of Health. 

The blanks used for collecting the data here presented 
are those recommended by the U. S. P. H. S. and certain 
data for comparison have been taken from "Epidemiologi- 
cal Studies of Acute Anterior Poliomyelitis" by Surgeon 
Wade H. Frost of this Service. 

It is not supposed that the following statistics include all 
cases of poliomyelitis that have occured in this state during 
the biennial period. There have, without doubt, been cases 
of the "abortive" type of this disease, in connection with 
each local outbreak. 

During 1912, there was no epidemic of this disease. Most 
of the 13 cases, however, occurred along old epidemic trails 
in the valleys of the Connecticut and Otter. 

Following somewhat the form of report made in the last 
two years, the incidence of the disease by months was as 
follows : — 



^Reprinted from Bulletin of the Vermont State Foard of Health, Vol. XIV, No. 4, June 
1, 1914. 

69 



70 



INFANTILE PARALYSIS IN VERMONT 



Poliomyelitis — Vermont — 1912 
Seasonal Distribution 



January 


F 1 


February 


k 


March 


-. 


April 




May 


■i 


June 




July 


■■2 


August 


WM2 


September 


ai 


October 


■> 


November 




December 


L 



Geographical Distribution 

In 1910, the majority of the cases in this state occurred 
on the East side of the Green Mountains, in the Connecticut 
Valley; in 1911, on the West side, on the Otter-Champlain 
watershed. 

In 1912, the cases were about evenly divided between 
these valleys. 

Poliomyelitis — Vermont — 1912 

Geographical Distribution 

EAST (Connecticut Valley) Counties 

Orleans 

Washington 

Windham 

Windsor 

Caledonia 

Essex 

Orange 



Total, 8 cases 




EPIDEMIC POLIOMYELITIS IN VERMONT 71 

WEST (Champlain Valley) Counties 

Rutland 

Chittenden 

Addison 
Bennington 

Franklin 

Lamoille 

Grand Isle 

Total, 5 cases 

The accompanying map shows the distribution graphi- 
cally. 

There were 8 males and 5 females in this series. 

Age 
The age distribution of these cases was as follows : — > 

Poliomyelitis — Vermont — 1912 
Ages 

Under 5 tpaSSS^BEBaBM 10 

5 to 10 Im 2 

10 to 20 
20 to 30 
30 to 40 gl 1 

The preponderance of cases under 5 years is, of course, 
not exceptional. 

Nationality 

American , 8 

Canadian 3 

Polish 1 

Italian 1 

The occupations of the family wage-earner were: 

Laborer 5 

Farmer 4 

Granite cutter 1 

Electrician 1 

Glazier 1 

Butter maker 1 




Poliomyelitis 

Vermont, 1912 

Vermont State 

Board of Health 



EPIDEMIC POLIOMYELITIS IN VERMONT 73 

The general sanitary surroundings of patients' houses 
were: 

Good 4 

Fair 7 

Bad 2 

Toilet facilities were : 

Water closets 7 

Earth closets 6 

The other data regularly sought with reference to this 
disease, such as character of the house (age, tenement or 
detached), soil conditions, proximity of factories, railroad, 
streams, etc., domestic animals kept, water supply, family 
history, personal history, presence of infectious diseases 
in the towns affected, first symptoms noted during the at- 
tack, revealed nothing extraordinary in this year. The 
cases occurred, like the old sporadic cases, lacking epidemic 
proportions, though mostly at old epidemic centers. 

Day on which paralysis occurred : 

1st 2 

2nd 3 

3rd 3 

4th 1 

Distribution of paralysis: 

All extremities 5 

Both legs 3 

One arm and one leg (same side) 2 

One arm and face 1 

One leg 1 

Both arms 1 

The severity of these cases is indicated by the extent of 
the paralysis ; also by the fatalities : 

Permanently paralyzed 4 

Complete recovery 4 

Died 5 

This, of course, is an exceptional mortality. The mortal- 
ity in scattered cases has usually been high in this state. 
Perhaps this is somewhat due to the overlooking of mild or 
abortive cases. 



74 



INFANTILE PARALYSIS IN VERMONT 



MEAN MONTHLY TEMPERATURES, BURLINGTON WEATHER 
BUREAU, 1912, COMPARED WITH NORMAL. 





Ja* 


Tetr 


Th^r 


Aft 


*«y 


Ti/n{ 


M 


Aug 


Scf 


Oct 


Tfov 


Pet. 


is 


























70 


























(,S 


























do 


























ff 


























fo 


























VS 


























Ho 


























iS 


























J0 
























\ 


JS 
























y\ 




























'f 


























T 


/ 
























5" 


/ 

























Normal (33 years), red line 



Monthly. means (1912) black line 



EPIDEMIC POLIOMYELITIS IN VERMONT 75 

The mortality under 5 years was 30% 

The mortality between 5 and 10 years was 50% 
The mortality over 30 years was 100% 

The average age of those who died was 8 years. Three of 
the 5 deaths occurred in cold months, viz. : December, Feb- 
ruary and March. 

No direct or indirect contact with the infection was trace- 
able in 10 cases. In the other 3, contact was probable or 
certain. In one fatal case, a subsequent history was ob- 
tained of a probable abortive case in the family two or three 
weeks before. One other instance of two cases in the same 
family occurred. 

2 cases occurred in families with 1 other child. 
5 cases occurred in families with 2 other children. 
4 cases occurred in families with 3 other children. 

1913 
The number of cases of poliomyelitis in the state took a 
sharp rise again in 1913. The disease assumed epidemic 
proportions in a section of Caledonia and Orleans Counties, 
centering about Hardwick. The features of the disease as 
it prevailed in the state are briefly as follows : 



Poliomyelitis — Vermont — 1913 
Seasonal Distribution 



January 

February 

March 

April 

May 

June 

July 

August 

September 

October 

November 

December 



12 



13 



76 



INFANTILE PARALYSIS IN VERMONT 



MONTHLY PRECIPITATION IN INCHES COMPARED WITH 

NORMAL, 1912, BURLINGTON WEATHER 

BUREAU FIGURES. 




Normal (35 years) red line _— 
Monthly totals (1912) black line 



Total precipitation for the year 34.14 inches. 
Mean precipitation for this locality, 31.56 inches. 

While the summer months of 1912 were dry, the precipitation for the 
year was rather above the normal. 



EPIDEMIC POLIOMYELITIS IN VERMONT 



77 



The epidemic in the northeastern section of the state 
started in July. The first case was in Hardwick, occurring 
on July 12th. The patient, who worked in a stoneshed more 
or less, was the son of a section hand on the railroad. (This 
patient had had tonsils and adenoids removed seven years 
before.) The epidemic in the Hardwick section culminated 
in September. Five of the July cases in the State occurred 
at Hardwick. The sixth occurred in Burlington — an isolated 
case. The scattered cases in Walden, Wheelock, Lyndon, 
Barton and other towns occurred during the months of 
August, September and October. Glover cases occurred in 
October and November. 



Counties 
EAST 

Caledonia 

Orleans 

Essex 

Windsor 

Windham 

Washington 

Orange 



Poliomyelitis — Vermont — 1 913 
Geographical Distribution 



25 



Total 40 



Counties 
WEST 
Addison 
Chittenden 
Rutland 
Lamoille 
Bennington 
Franklin 
Grand Isle 



Total 7 



78 INFANTILE PARALYSIS IN VERMONT 

The geographical distribution of poliomyelitis in Ver- 
mont from year to year is very interesting. The last marked 
outbreak of the disease in the state in 1910 showed 51 cases 
on the east side of the Green Mountains, in the Connecticut 
Valley, and 18 on the west, in the Champlain Valley. In 
1911, the west side of the state had 22 cases to 5 on the east, 
while in 1912, with only 13 cases reported in the state, there 
was no epidemic center and the cases were divided more 
evenly, 8 and 5. 

Of the 47 cases reported, 37 can fairly be assigned to the 
Hardwick outbreak. There was one other interesting and 
rather striking outbreak (4 cases) at Vergennes. Occur- 
ring late in the season, the first case in the series occurred 
on November 30th in the child of a liveryman. The disease 
was not recognized for some time and the possibility of 
stomoxys carriage was overlooked. 

The per capita occurrence of poliomyelitis in 1913 by 
counties and towns, where the epidemic cases occurred, was 
as follows: — 

Caledonia County 1 case to 1041 population 

Essex County 1 case to 2461 population 

Orleans County 1 case to 2593 population 

Addison County 1 case to 5002 population 

Hardwick town 1 case to 188 population 

Glover town 1 case to 155 population 

Vergennes City 1 case to 371 population 

These figures throw light on the seriousness of the out- 
break in the towns and counties chiefly affected. Orleans 
County was the epidemic center of the 1910 outbreak; the 
adjoining county of Caledonia had the greatest number of 
cases this year. The starting of the epidemic, as has been 
mentioned, was in Caledonia County, and the cases in the 
adjoining counties of Essex and Orleans, very likely, in 
some way owed their origin to those in Caledonia. 

Reference to the map, showing the geographical distribu- 
tion of the disease in the state in 1913, will show at a glance 
the clustering of the cases in this region. 



7ZZ1Z3»>^ /&"*"' 



80 



INFANTILE PARALYSIS IN VERMONT 



The following charts show the division of our cases this 
year by sex and age : — 



Male 
Female 



r 



Poliomyelitis — Vermont — 1913 
Sex 



28 



Poliomyelitis — Vermont — 1913 
Age 



16 



15 



Under 1 

1 to 5 

6 to 10 
11 to 20 
21 to 30 
Over 30 

The day on which the paralysis appeared in these cases 
was as follows : — 

Day Paralysis Appeared 

1st day 

2nd day 

3rd day 

4th day 

5th day 

6th day 

7th day 

After 7th day 

Not reported Sffl 2 

This chart shows nothing unusual, the preponderance of 
cases in this disease showing paralysis on the 2nd to 4th 
day. 

It has been noted by several observers that the relative 
proportion of males increases after adult life. The relative 
number of cases in males and females, as a whole, in Ver- 




Ratio of Males to Females Reported in Certain States 
in Recent Epidemics of Poliomyelitis 







Total 


Males 


Females 


Epidemic 


Cases 


Number 


per cent 


Number 


Per Cent 


Massachusetts 


1909 


620 


363 


58 


263 


42 


Minnesota 


1909 


332 


193 


58 


139 


42 


Iowa 


1910 


345 


200 


58 


146 


42 


New- York 


1910 


227 


118 


52 


109 


48 


Dist. Columbia 


1910 


246 


151 


61 


95 


39 


Vermont 


1910 


69 


40 


57 


29 


43 


Vermont 


1913 


47 


28 


59 


19 


40 



Chart showing the relative number of males and' females, at different 

ages, in Vermont, 1913. 



e/c 



o-i 



/-5 



6-/o 



f/-20 



-1/-30 



Oit-Y&o 



fo 



fo 



So 



yo_ 



3o 



Shaded spaces, Males. 



Blank spaces, Females. 



82 INFANTILE PARALYSIS IN VERMONT 

mont, in 1913, showed about the average preponderance of 
males. By age groups, however, the equal division in the 
second decade was somewhat unusual. 

Distribution of Paralysis 

One leg 12 cases 

Both legs 14 cases 

One arm 3 cases 

Both arms 2 cases 

Leg and arm (same side) 5 cases 

Both legs and arm 3 cases 

Both legs and both arms 3 cases 

Facial only 3 cases 

Deglutition 1 case 

Died before noted 1 case 

The involvement of the muscles supplied by cranial 
nerves in this disease is not unusual. Three cases in which 
the only noticeable paralysis was one side of face and one 
of the muscles of deglutition is perhaps a rather large pro- 
portion of 47 cases. Two of these cases occurred in the 
apparently isolated outbreak of four cases at Vergennes — 
one-half the whole number in that outbreak. 

The results in these cases, as far as can be determined 
March 1, 1914, are indicated in the following chart: — 

Results to March 1, 191U 

Fully recovered HB 1 

Some degree of ■ 

HnBBBBHBHSBBBHH9IHBHBHHDHHBHH3KIHBHBBHB42 

Died B— m 4 



There was no attempt made to identify or classify abor- 
tive cases, in the essential outbreak of which this is chiefly 
a report. That there were such cases in connection with the 
main epidemic in Hardwick cannot be doubted. Several 
frank cases of paralysis in this outbreak occurred in fami- 
lies and neighborhoods where other children had presented 
vague febrile or "grippy" symptoms. The lateness, how- 
ever, with which these suspicious cases were seen and their 



EPIDEMIC POLIOMYELITIS IN VERMONT 83 

present normal condition threw so much uncertainty on the 
nature of their symptoms that they are not considered in 
these statistics. Several paralyzed cases were certainly 
known to have been in contact with such doubtful cases. 

The sister of one adult case had symptoms, which pointed 
to an abortive attack of poliomyelitis, two weeks after the 
paralyzed case was taken sick. The symptoms she suffered 
were pain and weakness of legs and temporary loss of re- 
flexes. This apparently abortive case is not included in 
these statistics. 

The elimination from consideration of the abortive cases 
throws most of our cases into the "still paralyzed" column. 
Only one of the whole group is known now to have fully 
recovered, and this was a cranial nerve case with facial 
paralysis. 

Forty-two of these forty-seven cases, then, still show 
some degree of paralysis. This, in a few cases, could per- 
haps be better described at this time as a weakness of a leg 
or group of muscles. 

Recovery of function, however, in this large proportion 
of cases has not yet been complete. 

The next notable fact about this year's outbreak is the 
low mortality, viz., 8.5 per cent. 



Of 2 cases under 1 year, 50 per cent were fatal. 
Of 16 cases between 1 and 5 years, 12.5 per cent were fatal. 
Of 15 cases between 6 and 10 years, per cent were fatal. 
Of 8 cases between 11 and 20 years, per cent were fatal. 
Of 4 cases between 21 and 30 years, per cent were fatal. 
Of 2 cases over 30 years, 50 per cent were fatal. 



Two of the fatal cases occurred in connection with the 
main epidemic in and about Hardwick. The other two were 
apparently isolated or sporadic cases. It was observed (see 
Report of State Board of Health of Vermont, 1910 and 
1911) in the outbreak of poliomyelitis in this state in 1911, 
that all the deaths occurred in the cooler months (March, 



84 INFANTILE PARALYSIS IN VERMONT 

September, October, November and December) and that 
none occurred in connection with the chief epidemic. 

In 1913, of the four deaths, one occurred in May, not con- 
nected apparently with any epidemic center, one in August, 
an isolated case, and the other two in July and August, in 
connection with the Hardwick-Glover outbreak. 

An interesting coincidence (probably only this) was con- 
nected with the sickness and death of one adult — an isolated 
case, apparently. This man's brother had died of the dis- 
ease two years before in a hospital in New York State. 
There was no connection probably between the cases, al- 
though some of the clothing worn by the Vermont patient, 
prior to his illness, had formerly belonged to the brother in 
New York. The latter, however, had not been in contact 
with it after his illness began. This same patient, ten days 
prior to his illness, had spent an hour or two at a relative's 
house, in another Vermont town, where a young man had 
died of this disease twenty-two months before. 

One of the Hardwick cases was taken sick on the same 
day that a sister at their home, in a town twenty miles dis- 
tant, was taken with the same disease. The Hardwick cases 
had been in Hardwick only two days. This suggests that 
the origin of the disease in these children was the same. No 
contact with a prior case was discoverable, either direct or 
indirect. 

The symptoms shown in these cases during the acute 
stage were uniformly those common to the disease: fever, 
vomiting, pains in joints and extremities and constipation 
were quite regularly present. 

Respiratory failure was usually the cause of death, in 
fatal cases. 

The tabulated statement of the possible contact cases in 
this outbreak follows : — 

History of probable contact within 2 weeks 8 

History of certain contact within 2 weeks 6 

No history of contact within 2 weeks 33 



EPIDEMIC POLIOMYELITIS IN VERMONT 



85 



BURLINGTON WEATHER BUREAU CHART, 

SHOWING MEAN MONTHLY TEMPERATURES IN VERMONT, 1913, 

COMPARED WITH NORMALS. 





J*r\ 


Jet- 


7*aur 


fyf 


ytey 


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Tuly 


A«f 


$f 


6ct 


Ttov 


0*<L 


7S 


























7° 


























£5 


























(pO 


























f$ 


























6*0 


























is 


























ifO 


























3b' 


























30 
























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•If 
























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A* 


























It 


























/o 


























5 



























Normal (33 years) red line. _ 
Monthly means (1913) black line. 



86 INFANTILE PARALYSIS IN VERMONT 

MONTHLY PRECIPITATION IN INCHES AT BURLINGTON 

WEATHER BUREAU, VERMONT, 1913, 

COMPARED WITH NORMAL. 






^Sslfi* 


fdr 


/&&T 


htt 


7m) 


Tuiti 


Futy 


A*$ 


syt 


Oct 


Twvpzt 


s 


























V 


























3 


























X 


























1 




I 


' 















































Normal (35 yrs.) red line. — — 
Monthly totals (1913) black line. 



From these charts it will be seen that the summer of 1913 
was about normal as to temperature, but dry. The total 
precipitation for the year, 25.75 inches, was over 8 inches 
below the normal for this region. The dry season was very 
apparent. It was especially noticeable in Hardwick and 
vicinity. Streams were dry, also springs, and the village 
water supply in that town failed. The Lamoille River, which 
flows through the village, was at its lowest, with scarcely a 
perceptible stream. Drains and sewers emptied on its bank 
and into its nearly dry bed, and the village streets were un- 
sprinkled. Flies were correspondingly numerous. 

The same natural conditions, of course, obtained else- 
where. 

General Facts about the Cases 

Nationality 

American 33 

Canadian 5 



EPIDEMIC POLIOMYELITIS IN VERMONT 87 

Italian 3 

Spanish 3 

English 1 

Irish 1 

Scotch 1 



Chief Occupation of Parent or Wage Earner 

Farmer 10 

Laborer 7 

Stone cutter 8 



The remaining 22 cases were scattered among 20 occupa- 
tions. 

The occurrence of epidemic poliomyelitis in our state in 
the neighborhood of stone industries has been noted before. 
Hard wick is a granite-cutting town. Of the 17 cases occur- 
ring in that town, 8 were in the families of stone cutters. 
While Barre, the home of large granite industries, has here- 
tofore largely escaped visitations of this disease, Mont- 
pelier, Rutland, West Rutland and Proctor, centers of large 
stone industries, have suffered. Indeed, the first great out- 
break of this disease in this country, in 1894, occurred in 
Rutland County and was centered about its marble works. 
No special significance, has, so far as known, hitherto been 
attached to this coincidence of stone working and poliomye- 
litis. The Hardwick outbreak, however, after the experi- 
ences of these other stone-working towns, is noteworthy. 
The connection, of course, may be sought in local sanitary 
defects, or habits of the men who are engaged in stone 
working, rather than in anything inherent to the work it- 
self. 

General Sanitary Conditions 

These conditions are classified thus: — 

Good 18 

Fair 20 

Bad 9 



88 INFANTILE PARALYSIS IN VERMONT 

The toilet facilities in houses occupied by cases were : — 

Flush closet 23 

Privy 23 

Cess pool 1 

Previous health of patients for a month prior to the at- 
tack : — 

Good 41 

Poor 6 

It may be noted that none of these cases were ascribed to 
injuries, to bathing in streams or other bodies of water in 
hot weather, or to other infectious diseases. 

Large tonsils or adenoids in these cases were common. 
Those whose antecedent histories were described as "poor" 
had usually vague gastro-intestinal disturbances, or chronic 
weaknesses, or were described as "delicate children." 

Occurrence of Multiple Cases in Same House or Family 
Of the 47 cases, here recorded, 37 were single cases in a 
family or house. Six of these single cases occurred in fami- 
lies where there was one other child. 

14 occurred in families with 2 other children. 
3 occurred in families with 3 other children. 
5 occurred in families with 4 other children. 

1 occurred in family with 5 other children. 

2 occurred in families with 6 other children. 
1 occurred in family with 7 other children. 

This once more emphasizes the rather slight contagious- 
ness of the disease, as there is little likelihood that any of 
these other children escaped contact with the sick, after the 
disease developed. 

There were five instances of two cases in the same family. 

Occurrence of Cases on Traffic Routes 
Thirty-six of the cases occurred in railroad towns, 11 in 
towns away from the railroad. 

Hardwick is on a cross-state railroad. It is not a trunk 
line road or one with much traffic from neighboring states. 
In this respect it differs from the epidemic centers of for- 
mer years, like Brattleboro, Windsor, Barton, Rutland and 



EPIDEMIC POLIOMYELITIS IN VERMONT 89 

Burlington. The first case at Hardwick was in the family 
of a railroad section hand. This case occurred July 12. The 
next two cases occurred six and seven days later respec- 
tively. One of these two cases was on an isolated farm 
some two miles from Hardwick village, the other in the vil- 
lage. No known contact was traceable between these latter 
and the first case. 

Glover and Wheelock, not railroad towns, are on or near 
a thoroughfare much travelled by teams and automobiles, 
and it is noteworthy that the cases in these towns and Bar- 
ton occurred either late in the Hardwick outbreak, or after- 
wards, in October or November. 

That this disease follows lines of human traffic, rather 
than the valleys, through which sewage-polluted rivers flow, 
is quite obvious by a glance at the map. None of the La- 
moille Valley towns, below Hardwick, had a case of the 
disease. This, in spite of the fact that the railroad follows 
this valley nearly to its end. 

While this year's outbreak in this state has not been as 
extensive, or the cases as numerous as has happened in 
some former years, the intensity of the outbreak in Hard- 
wick has been unprecedented in recent years in Vermont. 
This record includes only such cases as were paralyzed. 
Vague and questionable cases, sometimes probably real "ab- 
ortive" cases, have been carefully excluded. This for the 
obvious reason that with our present facilities for diagnosis, 
there must be some question always about the genuineness 
of these cases. 

It should be stated that several experiments were made 
on monkeys in connection with the foregoing cases by Dr. 
B. H. Stone, Director of the Laboratory. 

In one adult case in 1912, 5 c. c. spinal fluid was taken 
by lumbar puncture and injected into frontal lobes of cere- 
brum of Rhesus monkey. The fluid was transparent and 
the result was negative. 




Poliomyelitis 

Vermont, 1910, 1911, 

1912 and 1913 

Total, 156 cases 

Vermont State 

Board of Health 



j j" *■";«"• Ir^i $ 5*T"*?' 

i l^J'Wl! 

F--// M ww^.# 

: ^: j-^SJ" ^'••"o'^T 

*- — J - . i * '? . . ; 9 s. : 



>t/r/rsr , 



f 



EPIDEMIC POLIOMYELITIS IN VERMONT 91 

Bedbugs taken from the bed in which the above case died 
were emulsified and introduced into the frontal lobe of a 
Rhesus monkey — results negative. 

Swabs from the throats and noses of eight cases and con- 
tacts in Hardwick were rubbed over the throats and noses 
of Rhesus monkeys without results. 

Watery emulsions of flies, taken from three infected 
premises at Hardwick, were injected into the cerebrums of 
Rhesus monkeys — all negative. 



POLIOMYELITIS IN VERMONT DURING THE FOUR YEARS 

1910-1913 

A review in brief of our experiences with this disease in 
Vermont during the past four years is interesting. A cur- 
sory glance at the accompanying map will show that the 
bulk of the cases in this state have occurred in a few locali- 
ties. Of the 156 cases reported in this state during this 
quadrennium : 

7 cases have occurred in Brattleboro, five of which were 
in one year (1910). 

24 cases have occurred in or near Rutland, 15 of which 
occurred in one year (1911). 

6 cases have occurred in or near Windsor, 5 of these in 
1910. 

8 cases have occurred in or near Burlington, 7 in 1910. 
8 cases have occurred in or near Vergennes, 4 in 1913. 

13 cases have occurred with Montpelier as the center, 8 
in 1910. 

65 cases have occurred in the northeastern counties of 
Orleans, Caledonia and Essex, centering about Hardwick 
and Barton. 

37 of these occurred during the outbreak of 1913, and 
24 occurred in 1910. These epidemic centers are all in larger 
river valleys with the exception of Barton ; are all on main 



92 INFANTILE PARALYSIS IN VERMONT 

traffic lines except possibly Hardwick, located on a cross- 
state railroad. 

A casual survey of the map for the four-year period shows 
the clumping of red dots about the centers mentioned, all 
on main thoroughfares through the state or on the larger 
streams. It should perhaps be repeated that the occurrence 
in the main valleys (on large streams) is very evidently due 
to the stream of human intercourse that takes these paths. 

This latter conclusion is emphasized by the almost com- 
plete absence of red dots on the map along the more moun- 
tainous portion of the state, north and south. That there 
are other influences at work, determining the epidemic in- 
cidence of this disease, than lines of human intercourse, is 
certain. Hardwick, somewhat off the main beaten path of 
railroad traffic, has had perhaps the severest visitation 
from this disease of any town in the state in recent years. 
Why this town, rather than St. Johnsbury, or Newport, or 
St. Albans, all on main railway lines, should suffer, is prob- 
ably to be answered by a search of local conditions. Exactly 
what these were, we may be able to answer sometime when 
the etiological factors in the spread of this disease are bet- 
ter known. Low rain fall, dust, filth of all kinds, perhaps 
the consequent multiplication of insects, must all be con- 
sidered. The infection was imported into Hardwick in some 
way, found a fertile soil in some local condition, and multi- 
plied accordingly. 

SUMMARY 

The foregoing completes such epidemiological studies as 
we could make of poliomyelitis in Vermont for the past 
four-year period. Only cases frankly paralytic have been 
included in our figures. 

The number of cases has fluctuated in such a way as to 
point to a three-year period for the recurring epidemic 
move. 



EPIDEMIC POLIOMYELITIS IN VERMONT 93 

1910 69 cases 

1911 27 cases 

1912 13 cases 

1913 47 cases 

It is hoped that continued epidemiological observations 
of this disease in our state may indicate any possible peri- 
odicity about its recurrence in the state as a whole, on the 
two sides of the Green Mountains (in the Connecticut and 
Otter-Champlain Valleys) as well as at the evident epi- 
demic centers of the disease in the state. 

Doctors Flexner, Clark, and Amoss, in one of the most 
recent publications from the Rockefeller Institute, record 
some experiments in monkeys with the virus of the disease, 
which show that a strain of poliomyelitic virus was propa- 
gated four years ; during this time it showed three distinct 
phases : first of low virulence, then of maximum and finally 
a return of the low virulence. They say "The cycle of 
changes in virulence is correlated with wave-like fluctua- 
tions in epidemics of disease, which also consist of a rise, 
temporary maximum and fall in the number of cases pre- 
vailing." It will be interesting to know if field observations 
of the periodicity of poliomyelitis outbreaks correspond 
with the results obtained experimentally. The same report 
of these animal experiments contains this, relating to the 
possible explanation of obscure outbreaks in remote locali- 
ties : — 

"In the light of this presentation the part played by spo- 
radic and abortive cases and of the microbe carriers of po- 
tentially epidemic diseases becomes more comprehensible. 
We may consider this class of infected persons or animals 
as carrying specific micro-organisms lacking high virulence 
for their respective kind. We may begin to see how the con- 
version, through favoring causes, of micro-organisms of 
low into others of high virulence, may be the signal for the 
appearance of epidemics, not necessarily confined to one 



94 INFANTILE PARALYSIS IN VERMONT 

place, but possibly arising almost simultaneously in sepa- 
rated and even remote places when the conditions are simi- 
lar; just as, on the other hand, the immediate transporta- 
tion of already elevated micro-organisms from a place in 
which an epidemic is already prevailing to new places may 
start similar severe outbreaks there." 

No rational or scientific explanation has yet been pro- 
posed to explain the sudden appearance of this disease in 
isolated country districts. Such cases, as is well known, 
occur in epidemic seasons and at other times. The disease 
is as apt to attack small children, who may never or sel- 
dom have been away from home or apparently had any 
communication whatever, for weeks before the attack, with 
the outside world. 

We may hope that the experiments mentioned above may 
help to solve the perplexing problem of the transmission of 
this disease, the origin of these obscure (sporadic) cases 
and the difference in virulence of individual outbreaks. 
While experimental proof has been adduced for the stable 
fly (Stomoxys) and bed bug theories of the carriage of this 
disease, these experiments have not been uniformly positive. 

The experiments, above referred to, of Dr. Flexner and 
his assistants, point to human agencies (the sick and "car- 
riers") as the chief factors in the spread of infantile paraly- 
sis. From these experiments we may infer an explanation 
of "abortive" or mild cases. 

Observed facts about the epidemiology of this disease 
have never fitted laboratory theories. If these recently re- 
ported experiments, showing the transition of organisms of 
low to high virulence, and then to low again, in animals, 
holds good in the human species, these experiments may 
prove highly important to a better understanding of the 
mysterious occurrence of cases of this disease. 

The whole trend of medical thought of late in regard to 
methods of dissemination of infectious disease has been 



EPIDEMIC POLIOMYELITIS IN VERMONT 95 

towards human rather than fomites, or animal, agencies. 
Contact with the frankly sick, convalescents, "missed" cases 
and "carriers" explains most of our cases and outbreaks of 
infectious diseases. Poliomyelitis may prove no exception 
to this rather general rule. 

The worst outbreaks here, as elsewhere, have not been in 
industries, rather significantly. As previously pointed out, 
this may be only a coincidence, the true significance lying 
in local conditions, or the character and habits of the 
workers themselves. 

Vermont is interested in the discovery of the cause of 
this disease, inasmuch as the state has suffered more than 
most from its ravages. For this, as well as other reasons, 
the State Board of Health will continue its epidemiological 
investigations of the disease and earnestly solicits the con- 
tinued help of the medical profession, as well as local health 
officials. 

SUGGESTIONS TO HEALTH OFFICIALS, PHYSICIANS AND 
OTHERS IN REGARD TO EPIDEMIC POLIOMYELITIS 

1. Poliomyelitis is a reportable disease. In the presence 
of an outbreak cases of sickness in children with vague 
nervous symptoms should be viewed with suspicion. Such 
symptoms are headache, convulsions, unusual general weak- 
ness, or weakness of a limb or group of muscles. In some 
outbreaks, grippy symptoms, sore throats, headache and 
general pains are quite common premonitory symptoms. 
The so-called "abortive cases" may end with these, and yet 
be as dangerous to others as frankly paralyzed cases. 

Practitioners are cautioned to be watchful for such cases, 
during the season of poliomyelitis (June to September). 
They should be reported and investigated. The statute re- 
quires reports of known cases and of suspicious cases. 

2. This disease is quarantinable. The full quarantine 
should be enforced four weeks. It is known that the disease 



96 INFANTILE PARALYSIS IN VERMONT 

is infectious, the infection is known, and it is communicable 
— although probably communicable to a limited extent. 
Every precaution must be adopted against its spread, in 
view of the disastrous results of every outbreak. 

3. Special attention should be given to the noses and 
throats in cases and in those in contact with cases. 

It is known that the nose and the throat may harbor the 
germ of the disease and that the germ may reach the brain 
and cord via these passages. 

Therefore the use of a 1 per cent solution of peroxide of 
hydrogen as gargle or nasal wash is best for cases and con- 
tacts. All excreta, especially all nasal and mouth discharges 
from cases should be disinfected. Heat is the safest disin- 
fectant. 

4. In the presence of the disease, insects (especially flies) 
should be carefully excluded from the sick room and house. 
Filth of all kinds, especially stable manure, should be re- 
moved and disinfected, the breeding places of flies destroyed. 
Street and house dust should be laid with water or oil. 

5. Terminal disinfection should be as thorough as in all 
diseases subject to the full quarantine. 

6. Do not forget that the disease may attack adults; and 
that it may occur in cold weather. 



EPIDEMIC POLIOMYELITIS 

A REVIEW OF THE EPIDEMICS 
OF 1914 AND 1915* 

By Charles S. Caverly, M.D. 

VERMONT has had an unusual experience with this 
disease. In the summer of 1894, the first consider- 
able outbreak that had been reported occurred in 
this state. This outbreak, comprising 132 cases, was con- 
fined almost exclusively to the Valley of the Otter on the 
west side of the Green Mountains. 

From 1894 to 1910 nothing approaching an epidemic of 
this disease appeared in the state. In the latter year, fol- 
lowing a rather severe outbreak in the Connecticut Valley 
in Massachusetts, the same valley in Vermont was invaded. 
Of 69 cases occurring that year, 51 occurred on the east 
side of the Green Mountains. 

This disease was made a reportable one at that time under 
the regulations of the State Board of Health. The "Full 
Quarantine" was enforced in these cases. This quarantine 
is the same as is practiced in the state with other major in- 
fections, like scarlet fever and diphtheria. 

The disease, without doubt, has been as fully reported 
since 1910 as was possible with the imperfect knowledge we 
have of its diagnostic points. The profession of the state 
has been generally aware of the possibility of local out- 
breaks, especially in rural communities, and has cooperated 
very generally with the State Board of Health in identify- 
ing these cases and applying preventive measures. 



♦Reprinted from "Bulletin of the Vermont State Board of Health," Vol. XVI, No. 4, 
June 1, 1916. 

97 



98 INFANTILE PARALYSIS IN VERMONT 

In 1911 there were 27 cases reported in the state, 22 of 
these were on the west side of the Green Mountains and 19 
of them in the same valley in which the original epidemic of 
1894 occurred. 

In 1912, there were only 13 cases reported in the state 
and these were quite widely scattered with no epidemic 
focus. Eight of these were in the Connecticut Valley and 5 
on the west side of the Green Mountains. 

In 1913, 47 cases were reported in the state. Forty of 
these occurred in the northeastern section of the state, and 
37 in Hardwick and its immediate vicinity. It should be 
noted that the last cases in this 1913 outbreak occurred in 
the town of Barton, only about 25 miles from Hardwick. 
Since 1910, the Passumpsic-Barton Valley in Caledonia and 
Orleans Counties has furnished the chief foci of this disease 
in Vermont. 

1914 

The epidemic of 1914, in the number of cases, as well as 
in mortality, was the severest that has ever occurred in the 
state. The epidemic began in the Village of Barton, the first 
cases occurring respectively on July 9, 18, and 22. The first 
cases occurred in the immediate neighborhood in Barton 
Village, where the last cases in the outbreak of 1913 oc- 
curred in the month of November. No other cases oc- 
curred in the state, as far as our records go, until the 30th 
of July, when the first case occurred in Burlington. The 
earliest cases in Addison and Franklin Counties were re- 
spectively August 16 and August 14. 

The outbreak of 1914 was chiefly felt in the northern 
half of the state above the forty-fourth parallel of latitude. 
Nearly 90 per cent of the 306 cases of which we have re- 
ports, occurred north of this line, which passes through 
Middlebury and Bradford. Scattering cases only occurred 
in Rutland, Bennington, Windsor and Windham Counties. 

The medical practitioners of Vermont, generally alert to 



EPIDEMIC POLIOMYELITIS IN VERMONT 99 

the seriousness of this disease, had had most unusual oppor- 
tunities for studying its various phases. The cases of the 
disease are undoubtedly diagnosed and reported by the pro- 
fession with increasing thoroughness. 

The following blank, which is a modification of the form 
recommended by the United States Public Health Service, 
was used in collecting most of the data this year, although 
the regular U. S. P. H. blank was used at first in Barton : 

Vermont State Board of Health 
Case Report of Acute Anterior Poliomyelitis 

Town 

Date of onset 

Date of paralysis (if any) 

Patient's name , age , Sex 

Nationality of father , of mother 

Occupation of father , of mother 

Residence (post office) , county 

Did patient live in city? , village? , country? 

If in country, state distance from center of nearest town or village 
, name of village - 

If this is the first case in your town, state distance to R. R. station 

, to livery stable , to a factory or stone or 

wood-working shop 

How near a stream , a pond , a lake 

Status of family : Well-to-do , moderate , poor 

General sanitary conditions : Excellent , good , 

fair , bad 

Previous general health of patient : Excellent , 

good , poor 

Tonsils : Large , unhealthy , normal 

Has patient adenoids? 

Had patient suffered from any illness, indisposition, or accident with- 
in a month prior to this attack? 

Nature of illness or accident 



Other Members of Family, Including Guests, Boarders and Servants 

Children : 

Males (age of each) 

Females (age of each) 

Adults : Males, number , females, number 

Were there any other cases of sickness in the family within one 

month before or after this attack? 

Give name, age, sex, date, and nature of each case 



100 INFANTILE PARALYSIS IN VERMONT 

Symptoms of Acute Stage 

Fever : High , moderate , slight , none . . 

Headache : severe , moderate , slight , none 

Constipation , diarrhoea , vomiting 

sore throat 

Pain , distribution 

Tenderness , distribution 

Retraction of head , restlessness , drowsiness . . 

Any bladder symptoms 

State whether paralyzed or abortive case 

Distribution of paralysis at its worst 



What treatment was employed, and with what apparent results? 
(a) In acute stage 



(b) Subsequent to acute stage 



Outcome of Case to Date 

Recovery (complete disappearance of paralysis) 

Improvement , extent of paralysis remaining 

Death , date 

If an abortive case, does the patient present any symptoms after the 
acute initial form subside? 

Contact with Previous Cases 
Had patient been associated with any previous case? with a sus- 
pected (abortive) case? 

give name, address, and date 

Had any member of the patient's family been associated with any 
previous case? ; if so, state whether paralyzed or ab- 
ortive ; give name, address, and date 



Did patient attend school? , where , grade 

Has patient been to any large public gathering? ; if so, place 

and date 

What were the weather conditions immediately preceding this attack? 

Hot , mild , cold , wet , 

dry , dusty , unusual in any respect 

Have any infective diseases, respiratory or digestive troubles been 

unusually prevalent in the community? 

What animals or fowls are kept on the premises? 

What insects are noted on the premises? < 

Has there been any paralysis of animals in the vicinity? 

What preventive measures were carried out? 

Remarks. — Please state any other facts of interest concerning the 
case 

Date of filling out report 

Signed , M.D. 

Address 



EPIDEMIC POLIOMYELITIS IN VERMONT 101 

Most of the cases were reported on these blanks by at- 
tending physicians or the inspector of the State Board. 

INCIDENCE OF THE DISEASE BY AGE AND SEX. 1914 

Of the 304 cases* recorded in this outbreak, in which age 
and sex are given, 167 were males and 137 females. 



[ 



Males ■HaUOBffiraHniHHninHaHEHHBHHUHBBaHi 167 
Females ■fflHnHRflnK3BHHHH!3HBBHHH£Hn^B^H 137 



The division of the cases by sex this year does not differ 
materially from the usual experience in these outbreaks. 
During the outbreak of 1910, the relative percentages were 
57 for males and 43 for females ; in 1913, 59 per cent males 
and females 41 per cent ; this year the percentage is divided, 
males 55 per cent and females 45 per cent. 

The occurrence of the disease by age periods was as fol- 
lows : 

Age Periods 

4 and under 

5-9 

10-19 

20-29 

30-39 

Over 40 

The combined distribution of the cases in the various 
counties, by age and sex, was as follows : — 






u& 


5-9 


10-19 


20-29 


30-S9 


U0& 




under 










over Total 




fM 


F 


M F 


M F 


M- F 


M F 


M F 


Addison 


4 


7 


3 6 


5 3 


1 


2 


31 


Bennington 


1 


1 










2 


Caledonia 




1 




1 




1 


3 


Chittenden 


15 


14 


9 9 


13 6 


2 4 


4 


76 


Franklin 


8 


6 


4 6 


3 4 


1 1 


2 


35 



*Two cases were reported later making the total number of cases 306. 
fM Male; F Female 



102 INFANTILE PARALYSIS IN VERMONT 





u& 


5- 


•9 


10-19 


20-29 


80-39 


uo& 




under 














over Total 




M F 


M 


F 


M F 


M F 


M 


F 


M F 


Grand Isle 


2 3 


1 







1 






1 8 


Lamoille 


6 2 


3 


2 


3 1 


1 






18 


Orange 


3 


4 


5 


2 4 




1 





19 


Orleans 


14 8 


9 


3 


8 7 


3 1 


1 


1 


55 


Rutland 


5 3 


4 


1 


3 1 








17 


Washington 


4 3 


4 


6 


3 4 


1 






25 


Windham 








1 








1 


Windsor 


3 3 


3 


1 


2 








1 1 14 



Total 62 54 44 39 43 31 10 6 7 5 1 2 304 

DAY ON WHICH THE PARALYSIS APPEARED 

The following table indicates the date of onset of the 
paralysis in those in which this detail is given. It will be 
noted that the paralysis appeared in this series of cases 
apparently a little earlier than has been observed in previ- 
ous epidemics. While it is possible that errors have crept 
into the records in this respect, by reason of the failure of 
parents to note early symptoms in small children, it is a 
fact that in a considerable number of cases the appearance 
of the paralysis was the first intimation the family had of 
the illness of the child. 

Onset op Paralysis 

1st day 53 cases 

2nd day 64 cases 

3rd day 53 cases 

4th day 43 cases 

5th day 15 cases 

6th day 10 cases 

7th day 10 cases 

After 7th day 9 cases 

DISTRIBUTION OF THE PARALYSIS 

The combinations observed in this series of cases of para- 
lyzed muscles and groups of muscles were quite complex. In 
only a minority of the cases was the paralysis confined to 
one extremity, or a single group of muscles. 

In the fatal cases, death was due to respiratory failure. 
Most of these cases were of the ascending type of paralysis, 



EPIDEMIC POLIOMYELITIS IN VERMONT 103 

all four extremities, or one or more of these being paralyzed 
frequently a day or two in advance of the respiratory symp- 
toms. In 18 of these cases, all of the extremities were para- 
lyzed prior to the respiratory paralysis ; in 5, both arms ; in 
7, one arm and one or both legs ; and in 9, the arm and leg 
on the same side of the body. Several of these cases showed 
paralysis of the muscles of deglutition and the neck. The 
distribution of paralyzed muscles in the cases that remained 
paralyzed, or that finally recovered without permanent 
paralysis, was extremely varied. It is impossible to classify 
in tables the parts involved except in a very general way : 



All the extremities were wholly or par- 
tially paralyzed in 19 cases 

Both arms in 9 cases 

Left arm alone in 8 cases 

Left arm and both legs in 6 cases 

Left arm and left leg in 3 cases 

Left arm and right leg in 5 cases 

Right arm alone in 10 cases 

Right arm and both legs in 6 cases 

Right arm and left leg in 5 cases 

Right arm and right leg in 9 cases 

Facial paralysis alone in 12 cases 

Both legs alone in 65 cases 

Left leg alone in 30 cases 

Right leg alone in 28 cases 



The remaining cases gave a great variety of paralyzed 
muscles and groups. One case had paralysis of the left arm 
and muscles of the neck ; another, "one arm" and the facial 
muscles; still another had paralysis of the right arm and 
right leg and the muscles of the right eye. The abdominal 
and spinal muscles were occasionally involved also with the 
extremities. 

The sixteen cases described as not paralyzed were cases 
usually in the families of frankly paralyzed cases, which 
exhibited symptoms very suggestive of the initial symptoms 
of poliomyelitis, like fever, vomiting, pains of back and ex- 
tremities, etc. 



104 INFANTILE PARALYSIS IN VERMONT 

A fact observed not infrequently, especially at Barton 
where such cases were of frequent occurrence in conjunc- 
tion with paralyzed cases, was this — in visiting and examin- 
ing a paralyzed case, one or more children in the family 
would be noted as not acting quite well. In questioning the 
parents of such children, it was learned that they had had 
acute febrile attacks, usually within ten days or two weeks, 
and had not fully recovered their strength. The appearance 
of these children was very striking, as compared with others 
in the same family who had not had such symptoms. They 
were appreciably pale, weak and listless. 

That, in all the communities where this disease appeared, 
there was a large number of such cases of varying degrees 
of severity, who recovered without any noticeable paralysis, 
there can be no doubt. These so-called abortive cases are 
surely important features of all outbreaks of infantile 
paralysis. The early diagnosis and control of these must 
have undoubtedly an important bearing upon the prophy- 
laxis of epidemic poliomyelitis. 

The records of this epidemic show that there were ten 
cases of crossed paralysis, i.e., one arm and the opposite 
leg, and 12 cases of the hemiplegic type. One case was ob- 
served in which the eye muscles of one eye alone were in- 
volved. 

The results of this outbreak of 1914, as determined by 
our reports dated from one to six months after the initial 
symptoms, were as follows: 



Paralyzed cases 226 

Died 53 

Fully recovered 27 

(Including those "not paralyzed") 



The mortality, therefore, in this outbreak was 17.3 per 
cent. The percentage of deaths by age periods was as fol- 
lows: 



EPIDEMIC POLIOMYELITIS IN VERMONT 105 

Percentage of Deaths 

By Age Periods 

Of 116 cases, 4 years or under 11.2% died 

Of 83 cases, 5 to 9 years 10.8% died 

Of 74 cases, 10 to 19 years 21.6% died 

Of 16 cases, 20 to 29 years 43.7% died 

Of 12 cases, 30 to 39 years 50.0% died 

Of 3 cases over 40 years 66.6% died 

Of 306 cases (total number) 17.3% died 

In 2 cases age not stated. 

The figures confirm previous observations as to the rela- 
tion of age to mortality in epidemic poliomyelitis. The older 
the subject, the higher the mortality. 

FEATURES OF THE EPIDEMIC 

The symptoms presented by these cases during the initial 
stage of illness were quite regularly fever, vomiting, more 
or less pains in joints and extremities, not unusually con- 
stipation and retention of urine. Pain and tenderness along 
the spine were very frequently noted. In a few cases, as 
has been before stated, the first symptom that attracted 
attention was the paralysis. 

The following table gives the number of instances in 
which there were one or more children under 20 in the same 
family with a frankly paralyzed case: 

Other Children under 20 in Family 



1 other child under 20 in family . . . 

2 other children under 20 in family 

3 other children under 20 in family 

4 other children under 20 in family 

5 other children under 20 in family 

6 other children under 20 in family 

7 other children under 20 in family 

8 other children under 20 in family 

9 other children under 20 in family 
10 other children under 20 in family 



55 instances 

51 instances 

36 instances 

27 instances 

19 instances 

13 instances 

4 instances 

1 instance 

3 instances 

1 instance 



As bearing on the communicability of this disease, a care- 
ful tabulation of the known exposures to both abortive and 
frank cases gives this result in our 306 cases : 



106 INFANTILE PARALYSIS IN VERMONT 

Instances in which no known contact could be traced 
with paralyzed, abortive or carrier case 238 

Instances in which contact with a supposed abortive or 
carrier case was shown 31 

Instances in which contact with a frank case was 
shown 37 

The following notes bearing on house infection are also 
interesting : 

In one family of nine children, three had "indigestion" 
with febrile symptoms seven to nine days before a frank 
case occurred. 

In one family of six children, there were two paralyzed 
cases eleven days apart. 

In another family of four children, there were two cases 
of frank paralysis seven days apart. 

In another family of six children, there were two para- 
lyzed cases, also seven days apart. 

In another family of five children and two adults, two 
children were taken sick August 22 and 26, respectively, 
one case proving fatal, and the father, thirty-eight years 
old, was taken sick August 26, and was one of the severest 
cases in the whole outbreak that recovered, being paralyzed 
in all extremities. 



Instances of One or More Cases in the Same Family 
Occurred as Follows 

In family with 2 children under 20 5 instances of two or more cases 

in either parents or children 
or both 
In family with 3 children under 20 5 instances of more than 1 case 
In family with 4 children under 20 2 instances of more than 1 case 
In family with 5 children under 20 2 instances of more than 1 case 
In family with 6 children under 20 3 instances of more than 1 case 
In family with 7 children under 20 2 instances of more than 1 case 
In family with 9 children under 20 1 instance of more than 1 case 
In family with 10 children under 20 2 instances of more than 1 case 

(1 paralyzed and 1 abortive) 

One fatal case occurred in a family in which there was 
a case three years before. 



EPIDEMIC POLIOMYELITIS IN VERMONT 107 

Many instances occurred in histories that were elicited 
from these families of symptoms very suspicious of abor- 
tive cases in other children. Such cases were corroborated 
in some instances, as has been before noted, by the appear- 
ance of such children. 

The above facts may or may not indicate a communicable 
disease. If, as seems likely, many "potential agents of dis- 
semination"* occur in family as well as community-life 
under epidemic conditions, the disease may be classed as 
really communicable. The bare fact, however, of only one 
or two frank cases of the disease often occurring in large 
families, indicates on the surface slight contagiousness. 

Prior Diseases 

Of diseases preceding the acute stage of the disease, a 
great variety were given. There was, however, not one dis- 
ease that could be positively given as a contributing cause. 
Grippy colds, gastro-intestinal diseases, attended with diar- 
rhoea and a generally debilitated condition, were oftenest 
mentioned, but even these figure in only an insignificant 
number of cases. 

There was one case undoubtedly mistaken for appendici- 
tis and the appendix removed on September 9, followed by 
paralysis the following day. 

Prior Injuries 

There were, too, a considerable number of histories of 
more or less definite injuries antedating the paralysis. 

One child with a paralysis of the left deltoid, arm and 
forearm had a fractured humerus ten days before on the 
same side. Another had a "broken arm" from seven to ten 
days before the attack, which proved fatal within forty- 
eight hours. In still another case, a fall and rather vague 



*Simon Flexner, M.D. "Modes of Infection and Etiology of Poliomyelitis.' 



108 INFANTILE PARALYSIS IN VERMONT 

injury or strain of the right arm was followed in ten days 
by the disease and paralysis of that arm alone. 

There were not the usual number of histories of "going 
in swimming," although a few were so reported. Six or 
seven eases of more or less vague injury to the head by 
falls and blows thereon were also reported. 

Tonsils and Adenoids 

Forty-four cases gave a definite history of enlarged or 
diseased tonsils. 

Three cases had been operated on for tonsils and ade- 
noids within three years. 

Occupations of Wage Earners, 1914 

The 286 cases, in which the occupation of the bread- 
winner of the family is stated, were reported as follows : 

Farmer 112 

Laborer 50 

Mechanic 16 

Teamster 11 

Stone-cutter 8 

Stone- worker 8 

R. R. employee 7 

Army officer 6 

Merchant 5 

Painter 5 

Plumber 5 

Blacksmith 4 

Mail carrier 4 

Lumberman 3 

Physician 3 

Milk handler 3 

Chauffeur 2 

Manufacturer 2 

Barber 2 

Carpenter 2 

Saloon worker 2 

Town clerk 2 

Telephone lineman 2 

Miscellaneous (one each) 22 

The condition of the premises and status of the family 
were reported as follows : 



EPIDEMIC POLIOMYELITIS IN VERMONT 



109 



Excellent 
Good . . 
Fair . . . 



Condition of Premises 



Bad 

Not stated 



64 

104 

99 

37 

2 



Total 306 

Status of the Family 

Well-to-do 52 

Moderate 165 

Poor 82 

Not stated 7 



Total 306 

In connection with the foregoing tables, a statement of 
the nationality of the parents in this series of cases is in- 
structive. 





Nationality 




Father 




Mother 






193 


American 


202 




74 


Canadian 


68 




10 


Irish 


- 7 




8 


English 


5 




3 


Scotch 


4 




8 


Swedish 


3 




2 


Russian 


3 




2 


German 


1 


German ........ 


2 


Italian 


1 




2 


Bohemian 


1 


Bohemian 


1 


Not stated .... 


11 




1 







No effort has been made to summarize the reports in re- 
gard to domestic animals, insects or vermin on premises. 
This epidemic occurred under distinctly rural surroundings, 
with the possible exception of the cases which occurred in 
Burlington. Cats, dogs, cows, horses and hens are the regu- 
lar accompaniments of all such premises. The unreliability 
of figures we have heretofore been able to collect in regard 
to insects and vermin have made any deductions from such 
statistics worthless. The epidemic occurred during "fly sea- 
son." The presence of flies of several species was almost 
universal. 



110 



INFANTILE PARALYSIS IN VERMONT 



Paralytic Diseases in Animals 
Instances of paralysis among domestic animals have al- 
ways been noted as accompanying our outbreaks of human 
infantile paralysis. There were a few such instances in 
connection with this outbreak of 1914. 

Instances of hens paralyzed on same farm .... 5 

Instances of paralysis in cows or calves 3 

Instances of paralysis in pigs 2 

Instances of paralysis in dogs 2 

DISTRIBUTION 

Seasonal 
The distribution of the cases during this year is shown 
in the following chart. The epidemic, as has been suggested, 
began in July, increased in August, reaching its climax in 
September, subsiding thereafter through the year. 

January- 
February 
March 
April 
May 
June 
July 

■■■■■■■HnHHBm 83 

September HHMHH9HBHn9iHHH 
October B 56 

November 



December 

It is only necessary to add that the seasonal curve of our 
cases in 1914 closely follows those of former years. August, 
September and October are the epidemic months in Ver- 
mont. 

Geographical 

While the southern half of the state is divided north and 
south by the Green Mountains, the same barrier does not 



EPIDEMIC POLIOMYELITIS IN VERMONT 111 

prevent intercourse between the east and west sides of the 
state in the northern half. As has been pointed out, the out- 
breaks in previous years affecting the southern part of the 
state have been quite largely confined to either the west or 
the east side of this mountain barrier and have shown some 
tendency to alternate between. 

The 1913 outbreak focused about Hardwick. The out- 
break of 1914 is traceable directly to that of the previous 
year, in that it started where the 1913 outbreak ended, viz., 
Barton. A reference to the map will show the widespread 
prevalence of the disease in 1914 over the northern half of 
the state. It will be further noticed that there semed to 
be two main foci, Barton and Burlington. Noticeable clus- 
ters also occur in and about Bristol, Barre, Waterville and 
St. Albans. (See Chart I, page 116.) 

The following table shows both the geographical and 
seasonal distribution of the disease. The division between 
the east and the west sides of the state is also given to con- 
form to previous reports. 

Seasonal and Geographical Distribution 

East 

County d *S rt o. rt 

£ & a < s 

Caledonia 

Orange 

Orleans 

Washington 

Windham 

Windsor 



West 



Addison 

Bennington 

Chittenden 

Franklin 

Grand Isle 

Lamoille 

Rutland 



Total 1 1 8 88 142 56 8 2 306 







-4-» 
O 

O 


> 

o 


o 

p 


Total 


1 


1 


1 






3 


1 


13 


3 


1 


1 


19 


7 32 


11 


4 


2 




56 


5 


12 


7 


1 
1 




25 
1 


4 


3 


7 






14 




118 


9 


15 


7 






31 


1 










2 


1 25 


44 


4 


2 




76 


4 


19 


12 


1 




36 


1 


4 


2 




1 


8 


4 


14 








18 


1 


6 


9 






17 




188 



112 INFANTILE PARALYSIS IN VERMONT 

The river valleys, as well as the railroad and highways, 
in the northern half of the state run east and west as well 
as north and south, so that human intercourse and travel is 
far freer between the two sides of the state north of Bur- 
lington than south. This may explain, and without much 
doubt, does, the wide and comparatively even distribution 
of the cases over the northern half of Vermont. 

Many questions might be raised with regard to the con- 
nection between the Barton and Burlington foci. A refer- 
ence to the map (page 116) emphasizes the importance of 
these two centers of distribution of the diseases in 1914. 

The outline map of the state (page 118), with some of the 
chief centers of the disease in 1914 marked in dotted lines, 
will show the sequence of the first cases in these centers. 
The first four cases of the outbreak, it will be noticed, oc- 
curred in Barton ; the next two in Burlington ; the seventh, 
in Middlesex ; the eighth at Cambridge ; and the ninth at St. 
Albans. The question of the connection between the early 
Barton cases and the first case at Burlington is an exceed- 
ingly important one, and one that, unfortunately, cannot be 
satisfactorily answered. Railroad and highway communica- 
tion between Barton and Burlington is, of course, easily 
possible, but only via certain other towns and villages, 
which seem to have escaped. A railroad journey from Bar- 
ton to Burlington necessarily would have to be broken at 
St. Johnsbury, or some other intervening point, and yet 
there was only a single case in St. Johnsbury, and that in 
the most rural part of the town. No other cases occurred at 
any other junction point between these places until some 
time later than the early Burlington cases. The tide of 
travel during the summer months through Barton is rather 
north and south than east and west. It would naturally be 
epected that carriers of this disease from Barton would dis- 
tribute the infection into Canada, via Newport, or to the 
towns in the Connecticut Valley, via St. Johnsbury and 



EPIDEMIC POLIOMYELITIS IN VERMONT 113 

Wells River — this entirely on the supposition that railroad 
travel is a chief factor in the distribution of this infection. 
The ubiquity of the automobile and the facilities it offers 
for communication in all directions over highways must not 
be overlooked in this connection. 

The part played by those "potential agents of dissemina- 
tion," abortive cases and human virus carriers in the dis- 
tribution of this infection need not be enlarged upon; nor 
need we dwell on the fact, now generally recognized, that 
man is probably the chief distributor of all forms of dis- 
ease organisms, and this includes the organism of infantile 
paralysis. The presumption, therefore, is that the Burling- 
ton focus, following that at Barton by about two weeks, 
owes its origin to the Barton center. 

The Chart, No. VII, which shows the cases reported 
chronologically, by weeks, will demonstrate rather vividly 
the chronological relation of these two centers in this out- 
break. 

Given the connecting link between the Burlington and 
Barton centers, the local foci shown on Map No. II at 
St. Albans, Waterville, Middlesex, and Bristol (Charlotte- 
Bristol) may be connected with the Burlington focus. 

Chart No. VIII shows the relation in time between the 
Burlington outbreak and another group of cases in six rural 
communities clustered together, fifteen to twenty-five miles 
to the south of that city. The two weeks' interval elapsing 
between the beginning and the culmination of the epidemic 
in each of these centers of infection is graphically shown in 
these charts. In each instance the facts are at least sugges- 
tive. This Charlotte-Bristol group may be taken as a typi- 
cal focus, representative of various other foci in Franklin, 
Addison, Washington and Lamoille Counties. 

While, therefore, we may fairly suspect that the Burling- 
ton infection came from Barton, we must also acknowledge 




Vermont Poliomyelitis 

1914 
State Board of Healtl 



I • - : fit *,4P:>J #~i—. < 

' • LfSH-J* • % XfCir**: \ 

J • fl/ -JT>#. * : 

t ^j-^J''Y-t' 1 '^ 

f-4/- M- MH^x&jgr ' 

! >f jn&k 1 / c$fc^. 

. 'J* I iff • >> rf^ 

h'q&- ••■MS..... Xl*D&* ;iF •©" 

ui l. .j#l. j Litfa* 



Chart No. I 



EPIDEMIC POLIOMYELITIS IN VERMONT 115 

that it is quite possible that the two centers are entirely in- 
dependent of each other. 

That there were other centers of this infection some- 
where in northern New England, New York or Canada, is 
entirely conceivable ; in which event, both of these foci may 
have been secondary to those in neighboring states. Against 
this hypothesis in the Barton case is the apparent connec- 
tion there between the 1913 and 1914 outbreaks. 

Both the chronological sequence of cases (II) and the 
chart (VIII) representing the relation between Burlington 
and the Charlotte-Bristol group tend to connect the cases 
which occurred after the middle of August in Franklin, 
Addison, Washington and Lamoille Counties like those in 
the Charlotte-Bristol group with the Burlington center. 

The presence in Burlington in July and August of circus 
performances and a merchants' carnival, naturally drawing 
on all the counties mentioned for patronage, would tend to 
confirm this supposition. 

It has been noted elsewhere in this country, and espe- 
cially in Sweden, that towns, which have had epidemics of 
infantile paralysis, are thereafter largely exempt from the 
disease for varying lengths of time. Wernstedt says, de- 
scribing the great Swedish epidemic of 1911 : "Some of the 
districts which were severely affected in 1905, were, during 
the epidemic of 1911 almost entirely encircled by cases of 
infantile paralysis. But notwithstanding this, they have 
themselves been left almost untouched by this later epi- 
demic." 

The mysterious exemptions during 1914 in Vermont 
were such towns as Lyndon, St. Johnsbury, Hardwick, Mor- 
ristown and other railroad towns, which would naturally be 
on the route of a human carrier traveling between Barton 
and Burlington. Hardwick, the center of the severe out- 
break of 1913, though cases have occurred in adjoining 
towns, has since been entirely exempt from the disease. Bar- 



r— -» 

i/f yHoosbutyr 



5 /\ 




f 2 



iSarto/i 



/ /f ^/Worcester 
%//f/W/esex 



Sequence of Cases 



Vermont Poliomyelitis, 1914 

Sequence of Cases in 

Epidemic Centers 



CHART NO. II 



EPIDEMIC POLIOMYELITIS IN VERMONT 117 

ton and the adjoining town of Irasburg suffered an out- 
break in 1910. In that year 8 cases occurred in Barton. At 
the end of the 1913 outbreak in this section of the state, as 
has been stated, Barton again had two cases. A four-year 
interval separated the two severe Barton epidemics. It will 
be interesting to note if Hardwick has a recurrence of the 
disease in 1917. 

Utterly inexplicable, too, is the fact that many small, 
sparsely settled rural townships off from main thorough- 
fares, like Waterville, Washington, Starksboro, Monkton 
and many others were severely visited. Many times the first 
cases in a town occurred in families whose members had 
not been away from home for several weeks and who had 
received no suspicious visitors. These are facts, of course, 
that have been widely commented on and can now only be 
explained as the result of contact with those "agents of dis- 
semination," the virus carriers. 

Of the towns in the state which suffered most severely 
per capita of population this year, the little town of Water- 
ville in Lamoille County heads the list. This town, with six 
cases, had a case rate of 12.4 per 1000 of population. Other 
towns followed in this order : 



9.2 per 1000 of population 

6.8 per 1000 of population 

5.9 per 1000 of population 
5.9 per 1000 of population 

5.4 per 1000 of population 

4.7 per 1000 of population 
4.2 per 1000 of population 

3.8 per 1000 of population 
2.2 per 1000 of population 
2.0 per 1000 of population 

1.5 per 1000 of population 

The greatest per capita incidence of the disease by coun- 
ties was in Orleans County, followed by Grand Isle, Addi- 
son, Chittenden, Lamoille and Franklin. 

Burlington, with 32 cases and a population of a little over 



Barton 


37 cases or 


Washington 


7 cases or 


New Haven 


8 cases or 


Bristol 


12 cases or 


Starksboro 


5 cases or 


Monkton 


4 cases or 


Hinesburg 


5 cases or 


Charlotte 


5 cases or 


Alburgh 


5 cases or 


Enosburg 


5 cases or 


Richford 


6 cases or 


Burlington 


32 cases or 



118 INFANTILE PARALYSIS IN VERMONT 

twenty thousand, did not really suffer so severely from the 
disease as many other small towns. It was without doubt a 
prolific center for the distribution of the infection. 

CLIMATOLOGICAL 

Temperature 
The temperature in Vermont during 1914 was not quite 
up to normal. The chart (No. Ill) gives the relation of the 
mean temperature for each month in the year 1914 to the 
normal for thirty-three years in the state. From this, it 
will be seen that June, July, August and September were 
rather below the normal temperature. 

Rain Fall 

A deficiency greater or less in rain fall has hitherto coin- 
cided in this state with outbreaks of infantile paralysis. 
Different sections of the state vary widely in the amount of 
rain fall. The accompanying chart (No. IV) drawn for the 
purpose of showing the rain fall departures in the state 
as a whole for eleven years, during the summer and fall 
months, gives the average of observations made at five sta- 
tions in the state, two of these government weather bureau 
stations at Burlington and Northfield; the other three vol- 
unteer observers at St. Johnsbury, Enosburg Falls and 
Wells. 

The zero line represents the normal with minus averages 
above this line and plus averages below. The lines repre- 
senting the departures from normal are the broken lines 
and give the months for 1914 complete up to November. 
This chart is an attempt to show graphically the dryness of 
the state, comparing this with the number of cases of infan- 
tile paralysis. 

The solid lines represent infantile paralysis outbreaks 
during the last six years. The year 1914, that in which oc- 
curred the extensive outbreak we are now considering, was 



EPIDEMIC POLIOMYELITIS IN VERMONT 



119 



AToJIL 



70 

60 
SS 

SO 
45 
40 
35 
30 
2S 
20 
/S 

to 



Temperature CfYA&-rjBu&L//YGT07y,V7:/3/<4 [ . 

jVo&/7AL*~33yEA/ZS~. 




r7EAN m /27/'4-< 


> 




Jany. 


fehy. 


Man 


Apt. 


May 


Jane 


My 


Aaf 


fep>L 


Oct. 


Nov. 


Dec. 




















J 


^^^ 























































































































































































































































































































































































































CHART NO. Ill 



^* 



for 



ac/np 



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TTT 



1 



r 




*qy 



7&9 



N 









ve# 



?*y 



'UP/* 




'39(7 



»<W 



■jpQ_ 



~WT 



dOPf 



VQY 



5! 

5^ 






ac/n/* 



™W 






yap 

for 



aoo. 



n 



'*<W 






i/y* 







acq/* 



»cw 



7*Q 



*sJ&K 



wr 



9t//y* 



r 






o 

< 
X 

u 



if 






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w 



w 



'$ny 



WT 



9pf>r 



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o 



, g? o 



bny 



~fi/»r 



oe*Z* 



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O 

3 



&2*s/?j se&(r // %/&/*& 



M 



JS 



-O. 



±r 






EPIDEMIC POLIOMYELITIS IN VERMONT 121 

an exceedingly dry summer. The April rain fall was very 
heavy ; thereafter, the balance of the year, exceedingly dry. 
The deficiency as a whole for that year at Burlington was 
9.94 inches. The summer of 1914 was apparently a very dry 
summer in the state as a whole. The summer of 1908, as 
shown on this chart, was even dryer, but there was no epi- 
demic that year. Something was lacking to start an out- 
break. Nineteen hundred and ten was dry in July and Aug- 
ust, but a wet September. 

This chart, as mentioned, must fairly show the rain fall 
of the State of Vermont, as a whole, during the eleven years 
it covers. The following table gives the temperature and 
rain fall figures from the Northfield Station, a station 
which more nearly represents Vermont conditions, as a 
whole, than any other single station. 



Temperature Rain Fall No. Reported Cases 

1890 40.4 38.17 

1891 42.6 31.11 

1892 41.3 32.57 

1893 39.5 31.36 

1894 42.6 28.92 132 

1895 41.6 35.20 

1896 40.8 33.82 

1897 41.4 39.14 

1898 42.9 30.52 

1899 41.4 27.36 

1900 41.6 34.11 

1901 41.6 31.42 

1902 41.2 38.33 

1903 41.2 29.09 

1904 38.1 27.66 

1905 40.0 32.31 

1906 40.7 34.75 

1907 39.6 37.77 

1908 41.4 29.07 

1909 40.8 31.98 

1910 41.2 31.71 69 

1911 41.5 27.92 27 

1912 40.0 37.07 13 

1913 43.4 31.35 47 

1914 39.3 30.08 306 

1915 42.4 28.95 44 

(Normal rain fall for 33 years 31.56 

Normal temperature for 33 years 43.00) 



122 INFANTILE PARALYSIS IN VERMONT 

Burlington figures, running back to 1828, show that the 
two lowest records of rain fall since that date were in the 
years 1894 and 1914 and were 22.62 and 22.96 respectively. 
Those two years were years of the greatest outbreaks of 
infantile paralysis which we have had. The Northfield fig- 
ures given above show that 1894, 1899, 1903, 1904, 1908, 
1911 and 1915 were the driest years. The temperature fig- 
ures seem to indicate nothing. 

From these discordant figures, it is perhaps impossible 
to make any positive deductions as to the relation of rain 
fall to epidemic poliomyelitis. "Seasonal dryness," however, 
is a quite regular field observation in connection with this 
disease with its accompanying low water, dust and insects. 
The official figures, it must be said, fairly uniformly sub- 
stantiate this observation. 

OUTBREAK IN BARTON 

As has been noted, the epidemic of 1914 started in the 
village of Barton and this village suffered more severely in 
most ways than any other in the state. The town of Barton 
is made up of several small villages and the usual farming 
districts about these. Two of the villages, Orleans and Bar- 
ton, are incorporated and on the railroad. Of the 37 cases 
that are reported from this township, 23 occurred in Barton 
Village; 3 in the Village of Orleans, and the other 11 in the 
farming districts of the town. 

Barton Village is a small manufacturing community of 
1330 inhabitants (1910). It is situated on Crystal Lake, 
whence the Barton River runs through the village. The vil- 
lage has a good water supply from a mountain pond and a 
fairly good sewerage system. Crystal Lake is a body of 
water three miles long and about half a mile wide. 

The principal industries of the town are wood-working 
shops, a foundry, three granite sheds, two grist mills and a 
garment factory. 



EPIDEMIC POLIOMYELITIS IN VERMONT 



123 



No.V. 



VILLAGE 



BARTON, VT. 




CHART NO. V 



124 INFANTILE PARALYSIS IN VERMONT 

As has been noted, the first case recorded in the state this 
year occurred near the railroad station in this village and 
rather near to the granite sheds and grist mills. In previ- 
ous reports of this Board, the possible connection between 
this disease and stone-cutting industries has been noted, 
from the severe outbreaks that have occurred in some other 
stone-cutting centers of the state. This may be, of course, 
a mere coincidence, as marble and granite industries are 
the chief industries of Vermont. It should be noted that the 
earliest cases in this outbreak were in the families of stone- 
cutters and all the earlier cases seemed to be directly con- 
nected by residence or employment with that section of the 
village near the railroad, which also contained the stone- 
cutting industries. 

The occupations of the bread winners in this Barton out- 
break were as follows: 

Laborers 6 

Stone-cutters 4 

Granite- workers 2 

Sundry other occupations (one each) 11 

It was found that several of the rural cases in the town- 
ship of Barton very possibly had been in contact with car- 
riers in Barton Village. A fair held in this village between 
the 15th and 20th of August gave a good opportunity for 
the distribution of the infection among visitors from the 
neighboring counties. It should be noted, however, that the 
epidemic had then reached its height and declined in Barton 
and the surrounding towns from that time ; so that the ef- 
fect of this fair on its spread is open to question. 

There were several instances of two or more cases in the 
same house in Barton, as will be seen by reference to the 
map of that village herewith produced (No. V). The dots 
enclosed in circles represent two and three cases in those 
houses. There was unmistakeable connection between sev- 
eral of the frank cases and other frank cases, as well as 
supposed abortives. 



EPIDEMIC POLIOMYELITIS IN VERMONT 



125 



The disease started in July and the last case occurred be- 
fore the middle of September. The greatest number of cases 
in the whole town occured during the week of August 16th 
and after the week of August 23rd there were only four 
cases distributed over three weeks. 

The schools of the town were not in session and none of 
the children affected had been in school for more than two 
weeks before they were taken sick. 

Of the 23 cases in this village 4 died, a mortality of 17.4 
per cent. 

Seasonal Distribution of Cases, Barton (Town) Outbreak, 

1914 



Week of July 5 


■ 1 


12 


■ 1 


19 


™ 2 


26 


DD3 


Aug. 2 


BB 2 


9 


■ ■mm hi 


16 


HBUHHHM 


23 


mmam ■■ 


30 


■ i 


Sept. 6 


■ i 


13 


WM2 



11 



BURLINGTON OUTBREAK 

The city of Burlington has a population of 20,468 (1910). 
The portion of the city located on the lake shore is chiefly 
given up to manufacturing, lumber and railroad yards. Al- 
though there are some very unsanitary residences in the 
southwestern section and on the northern outskirts, the 
greater part of the area of the city is occupied by well- 
located and spacious private residences and grounds. The 
extreme northern section has very small and crowded tene- 
ments, often very unsanitary. 



NaVI. 



CHART NO. VI 




bu r li ngton .vermont. 
Poliomyelitis — 1914. 

Vermoht State. Board of Meaitm 



EPIDEMIC POLIOMYELITIS IN VERMONT 127 

Aside from the lumber industries, there is a great assort- 
ment of minor manufacturing industries in the city, such as 
stone-cutting, cotton mills, and wood-working shops. 

The University occupies a large area at a considerable 
distance above and from the lake shore. Here, the dwellings 
and residences occupy spacious grounds and it may be stated 
with much emphasis that the city, as a whole, is as clean 
and sanitary as it is beautiful. There is little of the slum 
aspect to be seen anywhere. 

The city water supply is filtered lake water, taken from 
a considerable distance in the broad lake and the sewerage 
system finds an outlet on the lake front inside the break 
water. 

The accompanying map shows the location of each case 
that occurred in Burlington. Three-fourths of the cases oc- 
curred in the district north of Pearl Street. While this, per- 
haps, is not the most sanitary portion of the city, neither 
is it the most unsanitary, and most of the cases in this sec- 
tion did not occur in the worst portion of this section. 

The first case occurred on July 30 and most of the others 
followed during the month of August and the first half of 
September. The outbreak was rather evenly distributed 
over seven weeks. 

The first case reported was a boy, who was taken sick at 
a lake resort in the town of Charlotte, whose home was in 
Burlington. He had been at the lake from the 8th to the 
30th of July, when he became sick. Two weeks before com- 
ing down, however, he attended a circus in Burlington. 

In this connection, as has been mentioned, circuses were 
in Burlington on July 15 and August 21 and a week's carni- 
val occurred in the city from the 3rd to the 8th of August. 
There can be little doubt that these large public gatherings, 
drawing as they did on the surrounding country and espe- 
cially Franklin, Washington and Addison Counties, may 



128 



INFANTILE PARALYSIS IN VERMONT 



POLIOMYELITI S-VERMONT, 1914. Mx VIL 





Chart show/ms ttLATrort orBARTOTf outbreak to 




SuKLIHGTOM OUTBREAK, CMRO770LOG/CALLY 










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CHART NO. VII 



EPIDEMIC POLIOMYELITIS IN VERMONT 129 

have been a decided factor in the spread of this disease, not 
only in Burlington, but in the counties mentioned. 

As has been noted, this first case was the 5th in the state 
and the next case in Burlington, coming down on August 3, 
was the 6th case in the state. Neither of these cases, nor 
in fact any of the subsequent cases in Burlington, could be 
traced directly or indirectly to Barton or Orleans County. 

Chart No. VII shows the chronological relation of Or- 
leans and Chittenden County outbreaks and is interesting 
for this reason: the Chittenden County outbreak occurred 
subsequently to the Orleans County outbreak and at a 
proper interval of time to arouse suspicion as to their con- 
nection. As has been said, other connections cannot be 
traced. The Orleans County outbreak culminated at the 
middle of August, and that in Chittenden County, two and 
four weeks later, respectively, showed two culminating 
points. 

That Burlington furnished the infection for many other 
communities in neighboring counties is also extremely 
likely. 

The chart No. VIII, which shows the relation between the 
Burlington outbreak and the collection of cases that oc- 
curred in the contiguous rural communities of Bristol, New 
Haven, Monkton, Charlotte, Starksboro, and Hinesburg 
chronologically seems to point quite straight to Burlington 
as the origin of the infection in these towns. The disease 
began in this cluster of towns two weeks after the Burling- 
ton outbreak and had two points of culmination, each two 
weeks later than the highest point reached by the epidemic 
in Burlington. Each outbreak existed about the same length 
of time. 

The chart shows that the Burlington outbreak was rather 
evenly distributed over 6 weeks while the Charlotte-Bristol 
group of cases had two culminating points : one August 30, 
and the second one two weeks later. The general identity of 



130 



INFANTILE PARALYSIS IN VERMONT 



Poliomyelitis-Vermont, 1914. noyiu. 





Chart showing M 

3URJLINGTON ClTY ' 

*57'AR.rt<SBORO, OfATZZOT 


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dqfito 


ft>M 


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CHART NO. VIII 



EPIDEMIC POLIOMYELITIS IN VERMONT 131 

the curves, however, with the two weeks separating them 
is probably more than a coincidence. Two-week intervals 
seem to separate the crests of local waves of the infection, 
as note the two charts VII and VIII. Chittenden County 
and the Charlotte-Bristol group have two separated by that 
interval. 

The Burlington schools were closed at the time of this 
outbreak, of course, and none of the children had been in 
the public or parochial schools for fully a month before. 
Both the public schools and the University delayed opening 
in the fall three weeks on account of the outbreak. There 
are, however, two orphanages in the city which have, to- 
gether, about 280 inmates. One of these in which the greater 
number is was in the section north of Pearl Street, where 
the force of the epidemic was chiefly felt. No cases occurred 
in either of these institutions. 



FORT ETHAN ALLEN 

In the Town of Essex, six miles from Burlington, and 
connected by trolley as well as by steam and highway 
routes, is Fort Ethan Allen, a cavalry post. During the lat- 
ter part of August the disease attacked a child on this reser- 
vation and during the next three weeks six children had the 
disease, of whom three died. It is known that most of these 
children were exposed to each other. It might be said, too, 
that these cases occurred simultaneously with five other 
cases which occurred in the Town of Essex, in which is the 
fort. They were, evidently, cases of contact, if at all, with 
something farther away than the surrounding district of 
the town. The presumption is that these, like the Charlotte- 
Bristol group, may be with the other cases in Essex trace- 
able to the city of Burlington. All of these cases occurred 
under first-class, general, sanitary conditions. They were 
all in families of officers. 



132 INFANTILE PARALYSIS IN VERMONT 

PHILANTHROPY 

Not only will the year of 1914 be memorable in the public 
health records of the state because of the widespread and 
very serious outbreak of infantile paralysis which visited 
it, but because this dire event developed a form of practical 
philanthropy hitherto unknown in Vermont. An anony- 
mous friend of the state placed at the disposal of the State 
Board of Health a considerable sum of money for the pur- 
pose of doing independent and original research work into 
the nature of this baffling disease, infantile paralysis, and 
also for the purpose of placing the benefits of expert treat- 
ment within the reach of all those who had been maimed 
by previous epidemics. When this generous benefaction 
came to us, the Board at once called on Dr. Simon Flexner 
of the Rockefeller Institute of Medical Research, in New 
York City, for advice as to the best methods of using this 
gift. Three distinct lines of work were suggested and have 
since been carried out. First : an educational campaign for 
the purpose of giving the medical profession in the state the 
latest knowledge in regard to the diagnosis and prophylaxis 
of this disease, especially emphasizing the importance of 
abortive and carrier cases in its epidemiology. In pursuing 
this campaign the Board had the services of Dr. Francis R. 
Fraser of the Presbyterian Hospital in New York City, as 
well as of Drs. Amoss and Lovett, who were connected with 
other features of the work. Meetings were held at five dif- 
ferent points in the state and everything possible was done 
to arouse the profession to the importance of this disease 
and give them the best advice available. The second feature 
of the work undertaken was original research work into 
the nature of the infection, its methods of distribution, 
diagnosis, immunity, etc. This work has been in charge of 
Dr. Harold L. Amoss of the Rockefeller Institute in New 
York. A Research Laboratory was established in the Col- 
lege of Medicine, the University of Vermont, where Dr. 



EPIDEMIC POLIOMYELITIS IN VERMONT 133 

Edward Taylor is working under Dr. Amoss' direction. 
Reference is hereby made to the report of this department. 
The third and last line of work undertaken by the Board 
under this benefaction was the treatment of paralyzed 
cases. Dr. Robert W. Lovett, Chief of the Orthopedic De- 
partment of the Children's Hospital in Boston, has had full 
charge of this work. Again reference must be made to his 
report for details of the valuable work done and results 
obtained.* Not only have these Veralont cases been most 
surprisingly benefited, but with Dr. E. G. Martin of the 
Physiological Department of Harvard University, Dr. 
Lovett has evolved a method of measuring the strength of 
muscles, sound and impaired, which is likely to have far- 
reaching results in the management of this disease. 



1915 

In 1915, 44 known cases of infantile paralysis occurred 
in the state. After the very serious outbreak of 1914 and 
owing to the campaign instituted by the State Board of 
Health under its Special Fund, as mentioned above, the 
physicians of the state, as well as most of the citizens, were 
alert to the possibility of a recurrence of this disease in 
epidemic form. There was a general feeling in the profes- 
sion that the disease would not attack the northern part of 
the state, but might the southern this year. The sequel 
shows that we were again mistaken. The profession, gen- 
erally, were so alert to the possibility of outbreaks of this 
disease that the State Board of Health and the experts 
employed by it were in demand during the summer months 
for the purpose of investigating suspicious cases. Dr. Tay- 
lor, in charge of the research laboratory, personally inves- 
tigated many of these cases. Physical examinations and 
lumbar punctures were made in almost all for the purpose 

♦Journal A. M. A. Mar. 4, 1916. P. 729. 
Vermont Medicine. Feb'y, 1916. P. 36. 



134 



INFANTILE PARALYSIS IN VERMONT 



of diagnosis, and many autopsies were made by Drs. B. H. 
Stone and Taylor. It might be said in this connection that 
the number of cases of tubercular meningitis that devel- 
oped from these investigations was rather surprising. Many 
suspicious poliomyelitis cases proved to be that disease. The 
same blanks were used in collecting data in 1915 as were 
used in 1914. 

1915 
Poliomyelitis — Vermont 

Seasonal Distribution* 



January 






February 






March 






April 






May 


■ 1 




June 






July 


■■2 




August 


nnnra 19 


September 






October 


BHBBHHBBHlO 


November 




■ 7 


December 


■ 1 
ot stated. 




*One case n 





13 



It will be noticed in the above chart that the disease, as 
usual, occurred during the latter part of the summer and 
fall, culminating in September. 

The preponderance of male cases here shown is much 
greater than usual. 

Last year the Vermont cases were divided 55 per cent 
male to 45 per cent female. 

The 1915 Vermont cases numbered 68.2 per cent males 
and 31.8 per cent females. 

The age distribution in these cases is shown in the fol- 



EPIDEMIC POLIOMYELITIS IN VERMONT 



135 



lowing chart. Perhaps the only comment that is called for 
in this connection is the proportionately large number of 
cases between 10 and 19 years. 



1915 
Sex 



Male 
Female 



I 



30 



14 



The combined sex and age distribution according to coun- 
ties is given in the following table : 



4 and under 

5-9 

10-19 

20-29 

30-39 




111— II 1 Willi II Llll 1 " 


WM2 

HH3 



1915 
Age Periods* 

13 



13 



'One case age not stated. 



1915 
Sex and Age Distribution 



under 



5-9 



10-19 



20-29 



Addison 

Bennington 

Caledonia 

Chittenden 

Essex 

Franklin 

Grand Isle 

Lamoille 

Orange 

Orleans 

Rutland 

Washington 

Windham 

Windsor 

Not stated 

Total 



'M 



F M 
1 
9 

3 

1 



F 


1 
2 
1 



30-39 



M F M F M F 



2 



10 



*M Male; F Female. 



Total 

1 

1 

15 

4 
1 
1 

1 

1 
8 
3 
1 

1 
5 

1 



44 



While the majority of the cases occurred in "villages," 



136 



INFANTILE PARALYSIS IN VERMONT 



these villages are all distinctly rural. They are usually the 
typical New England villages, with small population rang- 
ing from, perhaps, 500 to 1,000 people. The essentially 
rural portions of the state were again rather severely vis- 
ited. Indeed, the apparent preference of this disease to 
rural life is conspicuous in the distribution of the disease 
this year. The nationality, occupation of wage earners, and 
general sanitary conditions are shown in the following 
tables : 

1915 
Nationality 

Mother 
American 29 



Father 






. 28 




9 




1 


German 


1 




1 







Polish 


2 




1 




1 


Total 


. 44 



Canadian 
English . . 
German . 
Austrian . 
Italian . . . 
Polish 
Irish .... 
Not stated 



Total 44 



1915 

Occupations 

Farmer 12 

Laborer 9 

Railroad section hand 2 

Traveling man 2 

Sundry other occupations (one each) 19 



Total 44 

1915 
Condition of Premises 

Excellent 8 

Good 15 

Fair 13 

Bad 8 



Total 44 

1915 
Status of Family 

Well-to-do 7 

Moderate 20 

Poor 17 



Total 44 



EPIDEMIC POLIOMYELITIS IN VERMONT 137 

1915 
Onset of Paralysis 

1st day 1 

2nd day 11 

3rd day 8 

4th day 10 

5th day 3 

6th day 1 

7th day 

Later than 7th day 3 

Not stated or not paralyzed 7 

Total 44 



DISTRIBUTION OF PARALYSIS 

As in 1914, a great variety of combinations were ob- 
tained in the muscles and groups of muscles affected in this 
milder outbreak of 1915. More delicate and precise methods 
of muscle-testing must continually bring to light more and 
more bewildering combinations of paralyses in these cases 
of infantile paralysis. The commonest paralyses noted in 
this outbreak, including the motor paralysis in several fatal 
cases, were: 

All extremities 3 

Left arm alone 1 

Left arm and left leg 1 

Right arm alone 1 

Right arm and both legs 1 

Right arm and left leg 1 

Both legs alone 3 

Both legs and certain trunk muscles 4 

Left leg alone 5 

Right leg alone 5 

Right leg and certain trunk muscles 2 

Aside from these 27 cases, there were, as usual, a number 
of cases in which the chief paralysis was hard to locate or 
in which it was vaguely stated. Such were "facial," "one 
leg," "neck muscles," "deglutition," "arm, neck and face." 

Results 
The end results in this series of cases are given in the 
following table : 



138 INFANTILE PARALYSIS IN VERMONT 

Paralyzed 24 

Died 11 

Recovered (abortive) 9 

Total 44 

Two facts are noticeable in the above table. The high 
mortality (25 per cent) is the first. The mortality in this 
disease of late years has run somewhere between 10 and 17 
per cent. The mortality of 17.3 in this state in 1914 in the 
large series of cases was very high. These figures for 1915 
are rather disquieting. It was believed by observers that 
the disease was really of a more malignant type, especially 
in certain towns. A second fact brought out by the above 
table is the large proportion of recovered (abortive) cases. 
This is easily explained. The attention of physicians had 
been so generally directed to the possibilities of a recur- 
rence of this disease in the state this year, that suspicious 
cases were very carefully investigated. It goes without say- 
ing that some of these cases which would formerly have 
passed for "colds," "grip," "indigestion" or "teething" 
were occasionally found to be really poliomyelitis. While 
our methods of making diagnoses in these cases are still 
very imperfect and unreliable, only such cases have been 
included in this list as there were good reasons for thinking 
belonged there. Some such reasons were: the occurrence 
of cases in conjunction with the frankly paralyzed children, 
the typical initial symptoms followed by prolonged invalid- 
ism, and finally the occasional detection of weak muscles by 
means of the methods devised by Drs. Lovett and Martin. 



FREQUENCY OF ABORTIVE CASES 

The frequency with which abortive cases occur in out- 
breaks of this disease is still uncertain. In the 1914 epi- 
demic of 306 cases, 26 were so classified. In outbreaks 
reported elsewhere estimates of the number of abortive 



EPIDEMIC POLIOMYELITIS IN VERMONT 139 

cases have varied widely. The ratio of paralyzed to abor- 
tive cases in Massachusetts in 1909 was reported as 3 to 1. 
In the same state in 1910, 4 to 1. In Iowa, 1910, the abor- 
tives were placed at 19 per cent of all. In Sweden the per- 
centage of abortives has been estimated in various out- 
breaks all the way from 15 per cent to 56 per cent. Careful 
observers would now place the proportion in most epidemics 
higher than formerly. For these reasons, the number of 
cases (26) classed as abortive in our 1914 epidemic was 
probably far under the truth. Our 1915 experience is more 
in keeping with the recent observations of this disease. 

Four brothers in a family in an isolated part of Wheel- 
ock came down with the disease; the first on October 22, 
the others following on October 31, November 1, and No- 
vember 2. One of these cases was fatal and one abortive. 
One case (Irasburg) occurred in a person who was said to 
have had the same disease 18 years before. There was one 
instance in which a clear connection was traced between 
two cases seven days apart and still another in which a par- 
alyzed case was in contact with an abortive seven days 
previously. 

The death rate by age periods in 1915 was as follows : 

Percentage of Deaths 
By Age Periods 

Of 13 cases, 4 years or under 30.7% died 

Of 12 cases, 5-9 years 16.6% died 

Of 13 cases, 10-19 years 23.0% died 

Of 2 cases, 20-29 years No deaths 

Of 3 cases, 30-39 years 66.6% died 

Age not stated in one case. 
Of all cases 25.0% died. 

References to the Map No. IX will show that the cases in 
1915 were quite generally distributed over the state. The 
only section suggestive of epidemic conditions is in the val- 



\r#4#A4ftf> 



\ ,"" "TY'T Y\c Aar l"olZ3»**n*r f*f* 

















.O^w/lt I c 



.- rf,.&2*4t Nay */?•< W°*>^ 

I >. J . \ \ l • -V-v'j'rtiO'' .' /".iiO-. r 



Vermont Poliomyelitis 

State Board of Health 

1915 



I \ *;...*.? 'mj •<*«*'«&*«>» 

;• ;. .. ^ ^f ><>: *« — . 

Ixn Xw '' JP 

i^V for pSM* ""* **»/»J£ ; 

K^....,i«: Llij... i >u<° 

• j>^ f p^wil «>* ft 'put 11 ? 

u& ipTV !/ i > 






Chart No. IX 



EPIDEMIC POLIOMYELITIS IN VERMONT 



141 



leys of the Passumpsic and Barton Rivers. One-half of all 
the cases occurring in the state this year were in these val- 
leys. This suggests an aftermath of 1914. 





1915 
















Seasonal and Geographical Distribution 








East 














County 


May June July Aug. 


Sept. 


Oct. 


Nov. 


Dec. 


Tota 


Caledonia 




1 


6 


5 


3 




15 


Essex 






1 








1 


Orange 




1 










1 


Orleans 






2 


4 


1 


1 


8 


Washington 




1 










1 


Windham 








1 






1 


Windsor 


1 


1 


1 




1 




4 
31 




West 














Addison 


1 












1 


Bennington 




1 










1 


Chittenden 




2 


1 




2 




5 


Franklin 




1 










1 


Grand Isle 




1 










1 


Rutland 


1 




2 








3 


Not stated 














1 



Total 



9 13 10 



44 



Eight of these cases occurred in September, 9 in Octo- 
ber, and 4 in November. The first case in this local area 
occurred August 26 in St. Johnsbury. Of the remainder of 
the cases in St. Johnsbury, 6 occurred during the month of 
September. 

The first case in Orleans County this year occurred Sep- 
tember 6 in Barton township. This case could not be traced 
to any possible connection with St. Johnsbury, unless, per- 
chance, some carrier or missed case from St. Johnsbury 
may have attended the Barton Fair, August 18, which was 
also attended by this case. It will be remembered that St. 
Johnsbury has almost entirely escaped cases of this disease 
until this year. Of the 8 cases occurring this year, 3 were 
fatal. 



142 INFANTILE PARALYSIS IN VERMONT 

Again it may be stated that 1915 was not a hot year, 
but was dry. Taking the Northfield figures, the mean tem- 
perature for the year was 42.4 against a normal of 43. The 
rain-fall deficiency, however, was marked, viz., 2.61 inches. 
The coincidence of our outbreaks of infantile paralysis, it 
may be repeated, with dry summer months, is at least 
significant. 

CONCLUSIONS 

A review of our experiences with this disease in Vermont 
warrants the following observations : 

The disease seems to be a rural disease. Something in 
rural life apparently favors its propagation and spread. 

The disease, while apparently following the arteries of 
human intercourse, makes long jumps between towns and 
attacks persons in isolated and inaccessible regions. 

August, September and October are the favorite months 
for the disease in Vermont. 

A community visited by an epidemic of this disease has, 
apparently, comparative immunity thereafter for several 
years. The experience of Barton might suggest a four-year 
period. 

As has been stated, poliomyelitis, under our regulations, 
is reportable and subject to "Full Quarantine" and terminal 
disinfection. In the present state of our knowledge of its 
epidemiology, there may be a theoretical question as to the 
utility of the quarantine. Practically quarantine measures, 
well carried out, appear to check community outbreaks. So 
in the absence of more positive proof of its inutility, we 
would not be warranted in abandoning it. 

In the presence of an epidemic, public gatherings, like 
picture shows, public, parochial and Sunday schools, fairs 
and circus performances, largely frequented by children, 
should be prohibited. 

In this connection, the following from Dr. Flexner's pa- 



EPIDEMIC POLIOMYELITIS IN VERMONT 143 

per summarizes our present knowledge of the ways the in- 
fection is spread: 

"The data which I have had the pleasure of laying before 
you have led me to believe, first, that the microbic agent of 
epidemic poliomyelitis is present in the nasal and buccal 
secretions and is carried by persons, not insects, and com- 
municated by them in such manner as to gain access to the 
upper respiratory mucous membranes of other persons, 
among whom a portion, being susceptible to the injurious 
action of the virus, acquire the infection and develop the 
disease. 

"The clinical variety or form of the disease which they 
develop may be the frankly paralytic, the meningitic, or the 
abortive and ambulatory in which no severe symptoms 
whatever appear. But however the persons may be affected, 
they become potential agents of dissemination of the virus 
of poliomyelitis, as do a number of healthy persons who 
have been in intimate contact with those who are ill, and 
another group of persons who have recovered from an acute 
attack of poliomyelitis. These several classes of infected or 
contaminated persons constitute the active means through 
which the virus is spread and to the control of which sani- 
tary measures designed to prevent epidemics must be di- 
rected." 

Finally, the writer wishes to acknowledge the assistance 
given by Dr. H. A. Ladd, Sanitary Inspector, in securing 
field notes of these outbreaks, and by Dr. C. F. Dalton, Sec- 
retary, in compiling these statistics. The work of Prof. 
J. W. Votey, Engineer of the Board, on the climatological 
data has been indispensable. 

To local health officers of towns invaded, especially to 
Dr. M. R. Prime of Barton, our acknowledgments are due 
for loyal support in carrying out the regulations of the 
State Board, and furnishing data for this report. 



INFANTILE PARALYSIS (POLIOMYELITIS) 
IN VERMONT 1916-1917* 

By Charles S. Caverly, Sc.D., M.D. 

1916 

THERE were 64 cases of this disease recognized in 
Vermont during the year 1916. The most of these 
cases, as will be pointed out, belonged probably to the 
outbreak which invaded New York and adjoining states 
from the severe epidemic which had its focus in Brooklyn. 

The earliest cases in Vermont appeared in Arlington, 
Pawlet, Poultney and Woodstock during the last of August. 
One case, in which the diagnosis was somewhat doubtful, 
had occurred in the town of Underhill on June 28. The real 
epidemic, however, started in Arlington, August 20. This 
was a late date for the epidemic occurrence of this disease, 
even in Vermont, where it has usually occurred rather later 
than in neighboring states. Four of the eight cases which 
occurred in Vermont during the last ten days of August 
were in this town. Three of these cases occurred in one 
family. Fourteen days previous to the first case, the father 
of the children had made a two days' trip through parts of 
Connecticut, Massachusetts and New York by automobile. 
The second and third cases in this family developed four 
and six days after the first. The fourth case in the town of 
Arlington occurred in a family, in which the grandmother 
of the child had been in contact with the father of the three 
children previously mentioned, eleven days before this 
fourth child was taken sick. These are the only facts elic- 



*Reprinted from Bulletin of the Vermont State Board of Health, Vol. XIX, No. 1, Sept., 
1918. 

144 



POLIOMYELITIS IN VERMONT— 1916-1917 145 

ited in regard to the origin of these first cases in our 1916 
outbreak. 

Cases of the disease, widely scattered, occurred in vari- 
ous parts of the state through September and October. 
Grand Isle in Lake Champlain, a sparsely settled island, 
had the most pronounced epidemic focus observed. These 
cases began about September 20. 

Because of the repeated experience with this disease dur- 
ing the last seven years, and because of the Special Fund, 
anonymously given to the State Board of Health for Polio 
work, we were better equipped for handling an outbreak 
than ever before. The progress of the disease, after its ap- 
pearance in New York in June, had been watched with in- 
terest here and cases were not unexpected. We had taken 
what seemed to us proper precautions early in the summer 
against the spread of this disease from New York City into 
our state. Infantile paralysis has been reportable in Ver- 
mont since 1910 and the Regulations of the State Board of 
Health require a full quarantine of twenty-eight days. This 
quarantine includes all persons on the premises. The disease 
is reported by the medical men of the state, as far as recog- 
nized, and the quarantine regulations are strictly observed. 
Data of this outbreak were collected on blanks similar to 
those used in Vermont for two years and these were filled 
out by either the attending physician, or by the Inspector 
of the State Board, Dr. Ladd, or the special investigator, 
Dr. Taylor. These data in condensed form follow: 



Incidence of the Disease by Age and Sex — 1916 

Sex 

Male M^aBK&BBBKMBBBBBMUnBBBMBKHMMBBBBBBBS^niBl 36 
Female BliUHG^HBHS^H^^HHEffH^nBBHH 28 



I 



Of the 64 cases occurring this year, 36 were males and 
28 females. Males 56.2 per cent, females 43.8 per cent. This 



146 INFANTILE PARALYSIS IN VERMONT 

is approximately the same division, as regards sex, that oc- 
curred in the great epidemic in this state in 1914. 

Among 1,081 cases studied in New York State this same 
year, the percentage of males was 53.4; while among the 
more than 9,000 cases, which occurred in Greater New 
York City, the males were slightly over 54 per cent. 

The following diagram represents the age incidence of 
the disease in Vermont this year. 









Age 
1916 






5 to 9 


L. 










10 to 19 

20 to 29 ! 
30 to 39 











- 


■ 5 







The percentage of young children in our Vermont epi- 
demics has been very low as compared with urban out- 
breaks. The number of children under five years of age in 
this epidemic was 22. This is 34.3 per cent of the whole 
number of cases; in 1914, of 304 cases, which occurred 
in the state, 38.1 per cent were under five. These figures 
are remarkably low, when compared with the figures for 
Greater New York in this 1916 epidemic. Of 9,345 cases in 
that epidemic, 77.3 per cent were under five years of age; 
and of 1,081 cases in New York State, outside of New York 
City, the same year, 50 per cent were under five. On the 
other hand, during our epidemic, 28 per cent of the cases 
were ten years of age or over; in New York City, the same 
year, only 3.6 per cent were ten years or over; and in the 
state, outside of the Greater City, 12 per cent were ten 
years of age or over. In other words, our percentage of 
young children to date has been very low, and of youth and 
adults high. 



POLIOMYELITIS IN VERMONT— 1916-1917 147 

In the Pennsylvania outbreak of 1910, the percentage of 
cases under five was 72. In Buffalo, in 1912, 75 per cent of 
the cases were under five; and in Springfield, Mass., and 
vicinity, in 1912, the percentage under five was 71. On the 
other hand, in the Iowa epidemic in 1910, only 24.3 per cent 
of the cases were under five. 

These figures suggest the question whether there may be 
something in urban life that increases the susceptibility of 
young children to this disease. 

The combined distribution of the cases by age and sex 
follows : — 





U& 


5-9 


10-19 


20-29 


30 & 






under 














over 


Total 




M F 


M 


F 


M 


F 


M 


F 


M F 




Addison 




2 








1 








3 


Bennington 


2 1 


1 





4 


1 


1 







10 


Caledonia 


1 





1 












2 


Chittenden 


1 3 





1 


1 


1 





1 




8 


Essex 





















Franklin 




1 















1 


Grand Isle 


2 2 


4 


3 


1 


1 





1 




14 


Lamoille 




1 















1 


Orange 


2 





1 









1 




4 


Orleans 











1 








1 


Rutland 


4 1 


6 


3 





1 





1 




16 


Washington 











1 








1 


Windham 


1 
















1 


Windsor 


2 
















2 



Total 15 7 15 9 6 7 1 4 64 

Onset of Paralysis 

Among 43 of these cases, in which the information was 
obtainable, the onset of the paralysis was on or before the 
4th day, in 74+ per cent. 

The following table gives the day on which the paralysis 
was first noted : — 

Same day 3 cases 

1st day 4 cases 

2nd day 13 cases 

3rd day 8 cases 

4th day „ 4 cases 



148 INFANTILE PARALYSIS IN VERMONT 

5th day 1 case 

6th day 6 cases 

7th day 1 case 

After 7th day 3 cases 

The distribution of the paralysis in these cases, excluding 
thirteen cases that were "abortive" and showed no paraly- 
sis, also one in which it was never determined whether 
there was any distinct paralysis, and one other in which 
the diagnosis was made post mortem was as follows: 

Distribution of Paralysis 

All the extremities were wholly or partially paralyzed in . . 1 case 

Left arm alone in 2 " 

Left arm and both legs in 1 " 

Right arm alone in 1 " 

Right arm and both legs 1 " 

Right arm and right leg 1 " 

Facial paralysis alone in 1 " 

Both legs alone in 9 " 

Left leg alone in 6 " 

Right leg alone in 8 " 

Respiration 3 " 

One leg 1 " 

Deltoid muscles and right side 1 " 

Legs and face 1 " 

Arms, bladder and respiration 1 " 

Whole body, except one arm 1 " 

Right side 2 " 

Left ankle and foot ,. 1 " 

Respiration, bowels and bladder 1 " 

Legs and respiration 1 " 

Both legs and bladder 1 " 

Complete paralysis 1 " 

Right arm and respiration 1 " 

Throat, respiration and arms 2 " 

Results 

Paralyzed cases who survived numbered 32 

Died 12 

Fully recovered, including abortive cases 19 

Died in another state 1 

Percentage of Deaths 
By age Periods 

Of 22 cases, 4 years and under 18.18% died 

Of 24 cases, 5 to 9 years 25.0% died 

Of 13 cases, 10 to 19 years 7.69% died 

Of 5 cases, 20 to 29 years 20.0% died 

Of 64 cases (All ages) 18.75% died 



POLIOMYELITIS IN VERMONT— 1916-1917 149 

Percentage of Deaths by Sex 

Of 36 male cases 5 died or 13.8% 

Of 28 female cases 7 died or 25.0% 



The usual mortality in cases of infantile paralysis is 
greater among the males than the females. The figures are 
reversed with our cases this year. The mortality this year 
was about the same as has happened heretofore in Ver- 
mont. In 1914 it was 17.3 per cent. In New York City this 
year the case fatality was 26.9 per cent. In that state the 
mortality was 23.7 per cent. In Boston this same year the 
mortality was 32.8 per cent, and in towns of 2,500 or less 
inhabitants in Massachusetts in 1916 it was 23.4 per cent. 
The mortality in any epidemic, of course, varies with the 
thoroughness with which the cases are diagnosed and re- 
ported. The more thoroughly the cases are reported, the 
less the apparent mortality in any epidemic of course varies 
with the thorough-abortive or mild, as well as paralyzed. 
In other words, rural poliomyelitis would seem to be of 
milder type than urban. 

As usual with this disease, there were numerous in- 
stances in which there were other children, in contact with 
the sick child in this outbreak, who escaped. The following 
figures represent such instances: 

Other Children under 20 in Family (Paralyzed Cases) 

1 other child under 20 in family 8 instances 

2 other children under 20 in family 14 instances 

3 other children under 20 in family 6 instances 

4 other children under 20 in family 4 instances 

5 other children under 20 in family 7 instances 

Two or More Cases in Same Family 

In families with 2 children under 20 — 2 instances of more than 1 case 
In families with 3 children under 20 — 5 instances of more than 1 case 
In family with 4 children under 20 — 1 instance of more than 1 case 
In family with 5 children under 20 — 1 instance of more than 1 case 



150 INFANTILE PARALYSIS IN VERMONT 

CONTACTS 

The more epidemics of infantile paralysis are studied, 
and especially the pre-paralytic symptoms, on which a diag- 
nosis of the disease may be based, the larger percentage of 
cases are found which may be reasonably ascribed to con- 
tact. In this epidemic of 64 cases, 15 were found to have 
been in contact with a frank paralytic case; three others 
had been in contact with either abortive or carrier cases, 
and in 46 instances no such contact could be traced. Thirty- 
nine per cent, in other words, of these cases, were traceable 
to possible contact infection ; while in the large epidemic of 
1914 in this state, only 22 per cent were so traceable. 

In 39 families with other children in this outbreak, in 
which cases occurred, only 9 developed secondary cases. 
While, therefore, contact infection seems to be increasingly 
traceable, it must still be considered a disease of rather low 
contagiousness. 

The three cases in the Arlington family before mentioned 
were the earliest cases that had occurred in the state. The 
possible connection which those cases had with the infec- 
tion in one of the neighboring states has also been men- 
tioned. The geographical distribution of the cases in this 
epidemic and the possible relation to New York cases, which 
this distribution suggests, will be mentioned later. There 
were several instances in which either the patient or some 
other member of the family had either been in contact with 
paralytic cases or had come from distant towns in this or 
neighboring states where the disease was prevalent. For 
instance, an adult female of twenty-three years of age, who 
had the disease in September in the town of Underhill, had 
been, for some weeks prior, in daily contact with a probable 
case sent from a city where there were cases in a neighbor- 
ing state to recuperate. This probable case had been sick 
some weeks before and had a weak arm and weak legs as 
the result. This case, together with three other persons 



POLIOMYELITIS IN VERMONT— 1916-1917 151 

from the same city, had visited in the family of the person 
sick in Underhill for two weeks before she was taken sick. 

Another instance of possible carrier infection occurred in 
the town of Brookfield. Three children in the family of 
A. J. were sick in September. A girl five years old was 
taken sick September 9. She died in convulsions on the 17th 
with paralysis of the legs. An autopsy done on this case 
showed unmistakable polio lesions of the cord. A boy three 
years old in the same family, taken sick on the 15th, died on 
the 18th, with paralysis of both arms and respiratory mus- 
cles. A baby in the same family, three months old, was 
taken sick with febrile symptoms and marked rigidity of 
the neck and spine, September 18. The sister of Mrs. A. J., 
who lived in Springfield, Mass., visited in Hartford, Conn., 
on August 27. At the house where she was staying was a 
child who was diagnosed that day as having poliomyelitis 
and died the following day, August 28. This woman and 
her husband immediately left the house in Hartford and re- 
turned to Springfield, and on September 3, they went to 
Brookfield, where they stayed until the 15th with Mr. and 
Mrs. A. J. The three children were taken sick from the 9th 
to 18th of September. These instances of possible infection 
are being more frequently noticed as the disease is being 
more carefully investigated. 

TONSILS AND ADENOIDS 

Not all of our cases this year were carefully examined for 
nasal or throat disease. Our records showed there were 
eighteen cases in which there were marked symptoms of 
adenoids or enlarged and diseased tonsils. One case had 
been operated on for adenoids within three years. 

OCCUPATION OF BREAD WINNER 

The occupation of the head of the family in these cases 
was as follows : 



152 



INFANTILE PARALYSIS IN VERMONT 



Laborer 22 

Farmer 20 

Teamster 4 

Slate quarry man 3 

Mechanic 6 

Marbleworker 2 

Various other pursuits (one each) 7 



64 

Other facts in regard to these cases were as follows : — 



Nationality 
1916 



Father 

American 36 

French 20 



Canadian 
Welsh . . 
Scotch 
English . 
Austrian 



64 



Mother 

American 33 

French 23 

English 2 

Welsh 2 

Irish 1 

Canadian 1 

Austrian 1 

Spanish-Mexican . 1 



64 

The distribution of the cases, by months, is represented 
on the following chart: — 

Monthly Distribution 
1916 

January 

February 

March 

April | 

May 

June 

July 

August S3RS9IDSHK32S n 

September BBBBBDHHBBBBHiBHl^B 20 

October B 22 

November 

December 

The real epidemic of the year began in August, attained 



POLIOMYELITIS IN VERMONT— 1916-1917 153 

its height in October, rapidly dying out with the approach 
of cold weather. 

The disease in New York City began early in June, the 
cases appearing in great number after the third week. The 
epidemic reached its maximum in August and declined 
thereafter gradually until November. 

The cases in New York State, outside of the city, began 
to appear in considerable numbers the first week of July; 
and those in Washington County, which is contiguous to 
Bennington and Rutland Counties in Vermont where the 
first cases of our epidemic appeared, occurred, one case 
the first week of July, and three or four more during the 
third and fourth weeks of August. The most of the cases, 
therefore, occurred at about the time that our epidemic be- 
gan. Viewed according to the seasonal occurrence of our 
cases, our outbreak may fairly be considered as a sequel to 
or part of the New York epidemic. In former years our out- 
breaks have begun in July, never as late as in this year. The 
coincidence in time with New York State cases just over the 
border strengthens the belief that our 1916 cases really be- 
long to the New York epidemic. 

The outbreak in Vermont in 1916 began a month later 
than the outbreaks we have had in former years. Our epi- 
demic this year began in August, and reached its height in 
October. 

Furthermore, it should be noted that the first cases oc- 
curred during the fourth week of August. The occurrence 
of the cases from that time until November 1, by weeks, 
was as follows : — 

August 26 6 

September 2 5 

September 9 4 

September 16 3 

September 23 9 

September 30 4 

October 7 7 

October 14 6 

October 21 4 

October 28 5 



154 INFANTILE PARALYSIS IN VERMONT 

The following chart shows both the seasonal and geo- 
graphical distribution of the cases in 1916. (These cases 
are divided between the east and west side of the natural 
state division, the Green Mountains.) 





Seasonal and 


Geographical 


Distribution 












East 














Counties 


d 






>, 

p 


bfl 

3 






> 

o 


ec. 
otal 






fe s 


< S A 


i— » 


< 


OT 


o 


£ 


Q H 


Caledonia 












2 






2 


Orange 


1 










3 






4 


Orleans 




1 














1 


Washington 










1 








1 


Windham 












1 






1 


Windsor 






West 




1 




1 




2 
11 


Addison 


















3 3 


Bennington 


1 


1 






4 


3 


1 




10 


Chittenden 






1 






2 


4 


1 


8 


Franklin 














1 




1 


Grand Isle 












5 


9 




14 


Lamoille 












1 






1 


Rutland 


1 








5 


3 


6 


1 


16 



3 2 1 11 20 22 2 3 53 

This year again there is a distinct one-sidedness in the 
prevalence of infantile paralysis, between the east and west 
sides of the Green Mountains. As has been before pointed 
out, these mountains are a distinct barrier to intercourse 
between the two sides of the state. In epidemics of commu- 
nicable disease, the effect of this barrier is bound to be ob- 
served. 

In considering our local outbreak in Vermont for the 
year 1916, the geographical distribution of the cases em- 
phasizes again the connection of our outbreak with the one 
in New York City. This year infantile paralysis appeared 
pretty generally throughout the east. The real epidemic 
focus was in the Brooklyn Borough of Greater New York. 
The disease began here early in the summer in June. Dur- 



POLIOMYELITIS IN VERMONT— 1916-1917 155 

ing July it assumed large proportions and was very evi- 
dently reaching out into New York State, Connecticut, 
northern New Jersey, Massachusetts, and more distant 
states. The wave did not reach Vermont, however, until 
late in August. 

The epidemic followed generally transportation channels 
with some notable jumps and exceptions. This is true 
usually of the disease. Infantile paralysis had been quite 
general during the winter and spring months. According 
to the Public Health Reports, 26 states had cases of the dis- 
ease between January 1 and April 30. The State of Virginia 
had the most cases. After the New York epidemic started 
there were many cases, occurring with increasing frequency 
in 30 states at least. The State of New Jersey had the great- 
est per capita number of cases of any state in the country 
for the whole year. The epidemic was especially severe in 
Jersey City and Newark. 

In general, it may be stated that the disease appears to be 
on the increase throughout the country. It may also be in- 
ferred, from the experience of 1916, that the disease is not 
nearly as much a rural disease as was formerly supposed. 
During 1916, many large cities suffered severely. In addi- 
tion to those mentioned, Philadelphia, Toledo, Baltimore, 
Boston, Chicago, Minneapolis and Providence were seri- 
ously invaded. Later in the year, after the disease was on 
the wane elsewhere, a focus appeared in West Virginia, in 
which there were 39 cases during the last three months of 
the year, although it was known that they were not com- 
pletely reported. Compared with many parts of the east, 
our Vermont epidemic was mild. 

It will be noted by reference to the accompanying map 
that most of our Vermont cases were clustered in towns 
close to the New York State border. 

Up to August 31, covering the period just before and at 
the commencement of our outbreak, there had been only 







Vermont 

State Board of Health 

Poliomyelitis, 1916 






I wr ~(-w f J* 4 

i~...... &S..J J y-/ *»*«*.■ -.a 

•*•-#• tt lmmiJ*5Jfr I 



POLIOMYELITIS IN VERMONT— 1916-1917 157 

four cases in Washington County, N. Y., which borders the 
southeastern counties of Vermont; and none in Essex and 
Clinton Counties, N. Y., which border the northern counties 
of our state. Indeed the northeastern section of New York 
was exceptionally free from cases. 

During September, however, there were two cases re- 
ported in Essex County, which borders the lower part of 
Lake Champlain. Fair Haven, Poultney, Pawlet, Rupert 
and Arlington are all in direct communication by rail with 
all of eastern New York and there is much interstate auto- 
mobile traffic between the two states at these points. Bur- 
lington and Grand Isle County are in less close contact with 
New York points by automobile routes and by steam boat. 
They have, however, close rail connection with the towns in 
Rutland and Bennington Counties, which were earliest in- 
vaded. The earliest cases in our epidemic occurred simul- 
taneously with the cases in the adjoining county in New 
York and the later and more severe outbreak in Grand Isle 
County occurred during the same month as the two cases 
reported in Essex County, N. Y. Clinton and Essex Coun- 
ties in New York are separated from Burlington and Grand 
Isle County by the lake and are less closely in touch with 
the site of our cases in these places than the towns in south- 
western Vermont. 

MANAGEMENT OF THE OUTBREAK IN VERMONT 

From long and varied experience with this disease, we 
had reason, in Vermont, to anticipate cases, when the very 
serious outbreak in New York City began to show itself 
the latter part of June. On July 6, the Board adopted the 
following regulations relating to children from Greater 
New York City: 

Vermont State Board of Health 
quarantine of children from new york city 
Infantile Paralysis (Epidemic Poliomyelitis) is prevail- 
ing to an unusual extent in the city of Greater New York. 



158 INFANTILE PARALYSIS IN VERMONT 

Families in that city in which there are children will 
naturally take such children as far as possible into the 
country. The State of Vermont has unusual reasons for 
taking extraordinary precautions against this disease. In- 
fantile Paralysis is generally recognized as a contagious 
disease and one that may be spread innocently by persons 
who have no clinical symptoms, in other words, by "abor- 
tive cases" or "healthy carriers." The State Board of Health 
of this State deems it reasonable under the circumstances 
to make the following rules and regulations ; therefore un- 
der the authority of Section 5419 of the Vermont statutes, 
the following rules and regulations are promulgated : 

1. No child under the age of fifteen years shall reside 
in this State for a period of more than twenty-four hours 
without being reported by an attendant, parent or guard- 
ian to the Health Officer of the town or city where such 
child is, provided such child has been in the city of Greater 
New York since the 20th of June, 1916. 

2. It shall be the duty of every housekeeper, manager or 
proprietor of every hotel or boarding house where such 
child is domiciled to immediately report such child, giving 
the name and age to the Health Officer of his city or town. 

3. Every such child shall be subjected to quarantine for 
a period of two weeks from the time such child was last in 
the city of Greater New York. 

4. The Health Officer of every town and city to whom 
such a child is reported shall immediately serve a written 
notice upon the head of the family in which such child is; 
this written notice shall contain a copy of these regulations 
and an order signed by such Health Officer requiring such 
child to remain on the premises in which it is at that time 
for the specified time of two weeks after last leaving the 
city of Greater New York. 

5. Each Health Officer to whom such child is reported 
shall require of the attendant, parent or guardian of such 



POLIOMYELITIS IN VERMONT— 1916-1917 159 

child, a certificate in writing, duly signed by a legal prac- 
titioner of medicine, certifying that the nose and throat of 
such child has been thoroughly washed with a solution of 
a teaspoonf ul of common salt in a pint of water, once a day 
for a period of three consecutive days before the premises 
are released from quarantine. 

6. No child under fifteen years of age shall enter any 
house so quarantined. 

7. A placard containing the word "Quarantine" shall 
be sufficient evidence to all persons that the premises are 
quarantined for the purpose of these regulations. 

Nothing in these regulations shall be construed to pre- 
vent other members of a household in which there is a child 
as above described, who has left the city of New York since 
June 20, 1916, from attending to their usual occupations. 

The owners, managers or proprietors of hotels and board- 
ing houses may place no restrictions on attendants or guests 
in their hotels or boarding houses further than the strict 
isolation of any children as above described from New 
York City, provided such children are isolated to the satis- 
faction of the local Health Officer and their noses and 
throats irrigated as specified. 

Each Health Officer will see that a copy of these regula- 
tions with which he is furnished is conspicuously displayed 
in at least three public places in his town or city. 

These rules and regulations will remain in force until 
further notice. 

Per Order Vermont State Board of Health. 

Charles F. Dalton, M.D., Secretary. 
Adopted July 6, 1916. 

In these regulations, it was sought to restrict the move- 
ment of children from the city and as far as possible to pre- 
vent their coming in contact, during a possible incubation 
stage, with other children in this state. Different munici- 



160 INFANTILE PARALYSIS IN VERMONT 

palities in the state adopted these or similar regulations 
against children from other parts of New York State and 
other states, as the epidemic spread out to these places from 
New York City. 

On account of the occurrence, during the latter part of 
August, of cases in the four southern counties of the state, 
the Board adopted the following regulations with regard to 
fairs, the annual Rutland Carnival, theatres and picture 
houses : — 

Vermont State Board of Health 
regulations adopted in regard to the attendance 

of children at public gatherings 
In accordance with the Vermont Statutes, the following 
rules and regulations are hereby promulgated by the State 
Board of Health : 

1. All children under fifteen years of age shall be ex- 
cluded from all fairs. The Rutland Carnival, so-called, shall 
be abandoned unless effective measures can be taken, satis- 
factory to the local board of health, by which children under 
fifteen years of age can be excluded from all public func- 
tions, both indoors and out. 

2. All motion picture houses and theatres in Rutland, 
Bennington, Windham and Windsor Counties shall exclude 
children under fifteen years of age from all entertainments. 

3. In towns in which there are one or more cases of in- 
fantile paralysis, all children under fifteen years of age may 
be excluded from all public gatherings, including churches 
and Sunday schools, in the discretion of the local board of 
health. 

These rules and regulations shall remain in force during 
the month of September, 1916. 

By Order of the State Board of Health. 
Charles F. Dalton, Secretary. 
Adopted August 31, 1916. 



POLIOMYELITIS IN VERMONT— 1916-1917 161 

These restrictions put upon children from New York 
City and discouraging the congregation of all children in 
certain parts of our state apparently accomplished what 
was intended by the State Board. A large number of New 
York children came to Vermont during the last days of 
June and early in July. Yet we had no cases in the state 
until the last of August. The disease had a good start in 
our southwestern towns at the end of August, yet there 
were comparatively few cases, and these scattered, after 
the promulgation of the last regulations, August 31. The 
situation at that time was certainly threatening. Refer- 
ence to the map will show that the cases were confined 
chiefly to the border towns. 

1917 

There were 171 cases of infantile paralysis in Vermont 
this year. There were three scattering cases of the disease 
in January, an unusual outbreak of six cases in March in 
Waterbury, and a severe epidemic in Washington County 
beginning early in June. Beginning with the outbreak in 
Waterbury in March, Washington County continued to be 
the center of the 1917 epidemic. 

The State Board of Health was well prepared, as in 1916, 
by reason of its Special Polio Fund, to meet the outbreak of 
1917. Dr. Edward Taylor, an experienced and expert diag- 
nostician, devoted himself wholly to the diagnosis, treat- 
ment and laboratory research work in the epidemic. Dr. 
Taylor had had charge of the work in 1916. The unusual 
clustering of cases in Washington County, especially about 
Montpelier and Barre, made it possible for him to see a 
large proportion of all the cases that occurred in the state 
and to see many of them very early, while they were only 
suspicious. 

As will be noted farther on, many so-called "abortive" 
cases were diagnosed; and several others, which showed 



162 INFANTILE PARALYSIS IN VERMONT 

some paralysis later, were also diagnosed in the prepara- 
lytic stage. In a large proportion of all the cases, lumbar 
punctures were made and the diagnosis decided by the find- 
ing of the microscope cell count and globulin content of the 
fluid. 

Incidence of the Disease by Age and Sex 

Male 




Female ■■uu«—^— — — — I e— — — " 78 



Of the 171 cases, 93 were males and 78 females. This 
division of the sexes does not differ materially from our ex- 
perience in former years. 54.3 per cent of the cases were 
males and 45.7 per cent females. 



Age Periods 1917 
■■nnBiaDBBHHnBBIBBBBBH 94 



23 



4 years 
and under 

5 to 9 
10 to 19 
20 to 29 
30 to 39 
40 or over 



The proportion of young subjects this year was larger 
than ever occurred in the state before. 54.9 per cent of the 
cases were four years and under. In 1916, this percentage 
was 34.3. In the great epidemic of 1914 in Vermont, the 
proportion of those four and under was only 39 per cent; 
whereas, in the severe epidemic in New York City in 1916, 
the percentage of cases under five years was over 80 ; while 
in the State of New York, as a whole, the same year, only 
49 per cent were under five years of age. 

Day on which the Paralysis Appeared 

1st day 14 cases 

2nd day 28 cases 



POLIOMYELITIS IN VERMONT— 1916-1917 163 

3rd day 33 cases 

4th day 32 cases 

5th day 12 cases 

6th day 7 cases 

7th day 3 cases 

After 7th day 10 cases 

No paralysis and not stated 32 cases 

Total . . . : 171 cases 



DISTRIBUTION OF THE PARALYSIS 

The combinations of muscular paralysis and weakness 
detected in this outbreak were more varied than ever be- 
fore. This was due chiefly to the facts that greater pains 
were taken in seeking out weak muscles and weak groups; 
and furthermore to the nicer methods of measuring mus- 
cular strength or weakness which have been devised by 
Doctors Lovett and Martin in their clinical orthopedic work 
in Vermont during the past three years. 

Of the 171 cases here recorded, in 139 there was some 
definite muscular impairment. The following list gives the 
distribution of the paralysis in these cases, as reported by 
the attending physicians and health officers. Most of these 
cases were diagnosed also by Dr. Taylor and many of the 
reports on muscles involved were afterwards verified by 
Dr. Lovett. 

All the extremities (including abdominal or respiratory) 8 

Both arms alone 2 

Left arm 4 

Right arm 2 

"One" arm 1 

Left arm and both legs 3 

Left arm and left leg 2 

Right arm and both legs 1 

Right arm and right leg 2 

Facial alone 6 

Both legs 35 

Left leg 20 

Right leg 20 

Both legs (including abdominal or respiratory) 6 

Respiratory alone 4 

Both arms (and respiratory) 2 

"One" leg 10 

Left leg (and abdominal or respiratory) 2 

Left arm and right leg 2 

Right leg (and abdominal or respiratory) 2 



164 INFANTILE PARALYSIS IN VERMONT 

In five instances the location of the paralysis is described 
as "one leg and facial," "one arm and abdominal/' "menin- 
geal type," "both legs and respiratory," "both legs, right 
arm, and respiratory." 

In several instances the exact location of the paralysis 
is omitted, and 23 cases are reported as "abortive." These 
latter cases usually occurred in families where there was a 
frank paralytic case, or, as sometimes happened in Mont- 
pelier and Barre, in the immediate neighborhood of such 
cases. Abdominal muscles were frequently involved in the 
paralysis. An unusual number of these cases were found 
at later clinics by Dr. Lovett to have such paralysis, and 
are not always so classified in our statistics. The cases in 
this report that are classed as abortive were given both 
careful clinical examination and examination of the spinal 
fluid. 

There were many more suspicious cases constantly ob- 
served in families where there was a paralytic case, which 
presented very suspicious symptoms. Such cases were fre- 
quently diagnosed as "grippy colds," "acute indigestion," 
"pharyngitis," and there were several cases, attended at 
first with skin eruptions, which were in several instances 
diagnosed early as German measles. 

Results 
The results in these cases, as far as they can be deter- 
mined from five to eight months after the first symptoms, 
were as follows : — 

Cases with residual paralysis or definite weakness 103 

Died 18 

Fully recovered 50 

171 
Most of these cases which still show muscular impair- 
ment have been seen at the clinics held by Dr. R. W. Lovett 
of Boston and the muscular impairment verified by him. 

The death rate in this series is remarkably low, viz.. 10.5 
per cent. The number of males who died was 10, and num- 
ber of females who died was 8. 



POLIOMYELITIS IN VERMONT— 1916-1917 165 

The percentage of death in males, therefore, is slightly 
greater than among the females. The death rate, as a whole, 
this year is lower than has ever occurred in any outbreak 
in this state. Our death rate in the epidemic of 1914 was 
17 per cent + ; the death rate in New York City in the 1916 
epidemic was 25 per cent +. The low death rate in this out- 
break may be variously explained. There were many slight 
and abortive cases included in these statistics. There were 
also a considerable number of cases, which received the 
most careful attention from Dr. Taylor and some of these 
were given quite early the immune human serum with ap- 
parent gratifying results. 

Percentage of Deaths by Age Periods 

Of 94 cases under five years of age .... 3.19% died 

Of 47 cases from 5 to 9 years of age . . 15.3% died 

Of 23 cases from 10 to 19 years of age. . 26.8% died 

Of 5 cases from 20 to 29 years of age 40% died 

These figures are noteworthy simply as showing, in a 
general way, an exceedingly low death rate. Taken in con- 
junction with the large percentage of cases that have ap- 
parently fully recovered, they emphasize the fact, before 
stated, that a considerable number of cases were diagnosed 
in this outbreak, which had comparatively slight paralysis 
with evident limited nervous lesions, and which, under older 
and less exact methods, would not have been detected. 

The mortality in this outbreak was really even lower than 
stated, inasmuch as three at least of the 18 fatal cases died 
so long after the onset of the disease as to make it quite 
probable that the cause of death was really something other 
than infantile paralysis. These three cases died from seven 
to nine weeks after the beginning of the attack. One of 
these cases is stated to have died of bronchial pneumonia. 
However, they are classed as fatal cases of infantile paraly- 
sis. Omitting these cases from the total deaths, our death- 
rate would be 8.77 per cent. 



166 INFANTILE PARALYSIS IN VERMONT 

CONTACT INFECTION 

Infantile paralysis has been usually classed as a disease 
of low contagiousness. All statistics, even now, tend to con- 
firm this view. This outbreak of 1917 in Vermont was quite 
carefully studied with reference to possible contagiousness 
in most of the cases. The following results are recorded : — 

Contact with a frank paralytic case, within 2 weeks, 24 cases 
Contact with carrier case, within 2 weeks, 13 cases 
Contact with abortive case, within 2 weeks, 8 cases 

A carrier, in this connection, was construed as a healthy 
person who had been himself in contact with a known case 
within two weeks. Supposed exposure to an abortive case 
was an exposure to other persons, usually children, in the 
same family, who had exhibited within two weeks suspi- 
cious symptoms. The more carefully individual cases of this 
disease are studied, the more are we able to explain their 
occurrence in this way. 

Children under 20 in the Same Family 

1 other child 53 instances 

2 other children 40 instances 

3 other children 24 instances 

4 other children 10 instances 

5 other children 7 instances 

More than 5 other children 4 instances 

"Several" children 2 instances 

Here are more than 276 children, in families in which 
there was one frankly paralytic case ; presumably, all these 
were at some time in contact with this case. Of these chil- 
dren, eight had the disease in paralytic form. 

Not all of these eight cases, however, were secondary to 
the first, as several of these were attacked simultaneously 
with the first, or within a day or two before or after. 

Twenty-two others of these 276 children had abortive at- 
tacks of the disease within two weeks, either before or 
after. Not all of these are included in these statistics. Care- 
ful inquiry, however, in most of the families, in which un- 
mistakable cases occurred, brought out the fact that at 



POLIOMYELITIS IN VERMONT— 1916-1917 167 

some time within two weeks of the case, there had been 
sickness, frequently of a rather vague character, among 
other children, when the symptoms presented approxi- 
mately a picture of the pre-paralytic symptoms in infantile 
paralysis. These cases were classed as possible abortive 
cases. For instance, in one family, a child had a sharp fe- 
brile attack, attended with vomiting and more or less pain, 
especially in the head and stiff neck for two days. This was 
followed in a week by a paralytic case that proved fatal. In 
another instance, in which there were five other children in 
the family of a case that was paralyzed, all of the five pre- 
sented gastro-intestinal symptoms with fever at about the 
same time. 

Of the 276 children included in these statistics, in families 
where there was a paralytic case, those that were ill, either 
with frank paralysis or supposed abortive attacks, were not 
all contact cases with the known infantile paralysis case. 
They were often taken sick at about the same time with 
that case. These figures corroborate the statement made 
before that while the disease is a communicable disease, it 
is one of low contagiousness. 

TONSILS AND ADENOIDS 

As far as the statistics of this outbreak were obtained, 
there were only 16 cases in which tonsils and adenoids were 
present. 

OCCUPATION OF WAGE EARNERS 

The occupation of the head of the family in these cases 
was as follows : — 

Blacksmith 4 

Clerk 8 

Dead 4 

Engineer 3 

Farmer 27 

Fireman 2 

Granite cutter 12 

Insurance , 4 

Iron worker 3 

Junk dealer 2 



168 INFANTILE PARALYSIS IN VERMONT 

Lumberman 4 

Lawyer 2 

Laborer 8 

Machinist 2 

Mill work 4 

Merchant 3 

Painter 2 

Printer 2 

Paper maker 2 

Quarryman 5 

"Stone" cutter 21 

Traveling salesman 2 

Talc miner 2 

Veterinary surgeon 2 

Not stated 10 

Miscellaneous (one each) 31 

Total 171 

Montpelier and Barre, which were the centers of the dis- 
ease this year, are granite producing cities. It would be 
quite natural, of course, that a large proportion of persons 
in those places affected by any disease should be stone 
workers. It is, however, a significant fact that of these 171 
cases, 38 occurred in the family of persons engaged in the 
stone industry. In reporting the outbreak of 1913 in this 
state, which centered about Hardwick, attention was called 
to the comparatively large number of cases that occurred 
in that town in the families of granite cutters. No connec- 
tion has been traced between the stone-cutting industry and 
the dissemination of this disease. This fact, however, is 
worthy of repetition; a seemingly large proportion of the 
cases of infantile paralysis in this state during the last 
nine years have occurred in the families of those connected 
with stone working industries. 

The population chiefly affected by this outbreak of 1917 
in Montpelier and Barre was very cosmopolitan, as shown 
by the following table : — 

Nationality 1917 

Father Mother 

American 97 95 

American-French 2 1 

American-Irish 6 9 



POLIOMYELITIS IN VERMONT— 1916-1917 



169 



Austria 
Canadij 
English 
French 
French- 
Irish . 
Italian 
Jewish 
Mexicai 
Not sts 
Swedisl 
Spanis! 
Scotch 


n 




Father 



Mother 
1 


in 




3 


4 






3 


1 






.. 11 


14 


■Irish . 




1 







3 


6 






.. 20 


17 






2 


3 


i 




1 





ited . . . 




6 


6 


i 




3 


3 


i 




3 


4 






.. 10 


7 




Seasonal Distribution 
1917 

■ 6 


171 




January 

February 

March 

April 

May 

June 

July 

August 

September 








171 


































October 




HH8 




November 
December 


■ 1 









The noteworthy fact, brought out by the above chart, is 
the comparatively early occurrence of the disease this year. 
The months in which Vermont has chiefly suffered from in- 
fantile paralysis have been August, September and October. 
This year the outbreak may be said to have begun in March, 
as it is quite probable that there was some connection be- 
tween the March cases in the town of Waterbury and the 
later severe outbreak in Barre Town, Waitsfield and Mont- 
pelier. 



170 INFANTILE PARALYSIS IN VERMONT 

GEOGRAPHICAL DISTRIBUTION 

A reference to the map will show that the cases chiefly 
clustered about the center of the state with Montpelier as a 
focus. Montpelier, Barre (city and town), Waterbury and 
Waitsfield were the towns chiefly invaded. St. Albans and 
Woodstock each had several cases, the latter being the cen- 
ter of a small outbreak. Of all the cases in the state, how- 
ever, 80 per cent occurred in Washington County; and. of 
the towns of Washington County, the city of Montpelier 
suffered by far the most severely. 

As has been noted, there were six cases in the town of 
Waterbury in the early spring (March). It was impossible 
to trace the origin of these cases, occurring at this unusual 
season, with a monthly temperature mean of 26°. 

Waterbury, as far as the records of the Health Depart- 
ment of the state go, had had only three cases of the disease 
in prior years, viz., 1 in 1912 and 2 in 1914. If the virus 
may remain dormant under unfavorable conditions for four 
to six years, as shown by Flexner and Amoss, these prior 
cases may possibly have given rise to this fresh outbreak. 
Its importation at this season hardly seems likely. The next 
cases occurred in Barre Town, Waitsfield and Montpelier. 
Barre City, it will be remembered, lies between Barre Town 
and Montpelier. After the Waterbury outbreak in March, 
no cases were reported in the state until the 7th of June, 
when a single case occurred in the town of Barre. The next 
cases occurred the 15th, 16th, 17th, 18th and 19th of June 
simultaneously in Barre Town, Waitsfield and the City of 
Montpelier. No explanation of this case in Barre Town is 
obtainable, further than that the child attended a Decora- 
tion Day celebration eight days before. 

The cases multiplied very rapidly in Montpelier, Waits- 
field and Barre Town simultaneously from the middle of 
June to the middle of July. Barre City escaped entirely un- 
til July 6 when a single case was reported. This case was 



POLIOMYELITIS IN VERMONT— 1916-1917 171 

one of facial paralysis and was not seen by any physician 
for three weeks after the development of the paralysis. The 
only history obtainable in this case was that the child had 
played with a child in Montpelier the week before the onset 
of the disease. This case may have infected others, who sub- 
sequently developed the disease. Barre City escaped a gen- 
eral epidemic until the middle of the month. From the 16th 
of July on, scattering cases occurred in the city through 
August and September. Barre Town, Montpelier City and 
Waitsfield bore the brunt of the epidemic. These with Wa- 
terbury, which was the scene of the March outbreak, were 
the most severely attacked by the disease. It would be diffi- 
cult to determine any condition favorable to the spread of 
infantile paralysis, common to these four towns, that did 
not also include Northfield, Berlin, Moretown and other 
neighboring towns. Waitsfield, a small town of 789 inhabi- 
tants, twenty miles or so from the railroad, and even fur- 
ther from Montpelier and Barre, had the most cases per 
capita of population of any town. Berlin, Northfield and 
Moretown, lying between Waitsfield, Barre and Montpelier, 
had altogether only two cases, one each in Moretown and 
Berlin. 

The number of cases, per thousand of population, in these 
towns chiefly affected, was as follows : 



Moretown 15.5 

Montpelier City 6.8 

Barre Town 3.8 

Barre City 2.04 



The town of Middlesex, lying directly between Water- 
bury and Montpelier, had but four cases, and these all oc- 
curred after August 1, i.e., rather late in the epidemic. 
The same may be said of the cases that occurred in Wood- 
stock, Pomfret and St. Albans. 

The following table shows the number of cases of inf an- 






172 INFANTILE PARALYSIS IN VERMONT 

tile paralysis that have occurred in Washington County and 
the whole state during the past eight years. 



State of Vermont Washington County 

1910 69 12 

1911 27 1 

1912 12 1 

1913 47 

1914 304 25 

1915 44 1 

1916 64 1 

1917 171 137 



In all of these years Montpelier City has had but three 
reported cases of the disease and those in 1910. It will be 
noted by the above figures that Washington County had a 
few cases in 1910, more in 1914, and the severe outbreak of 
1917, here described, which reached the large proportions 
of 137 cases ; and furthermore, that the City of Montpelier, 
which was chiefly involved in this year's epidemic, 54 cases, 
has never before suffered a severe outbreak of infantile 
paralysis. Basing our prophecy on past experience with this 
disease, Montpelier and possibly the most of the towns in 
Washington County will be comparatively immune to infan- 
tile paralysis for the next three years. 

The map, herewith published, shows that the eastern side 
of the state, and especially Bennington, Chittenden, Addi- 
son and Rutland Counties, almost entirely escaped; also 
Windham County, Essex, Orleans and Caledonia. In fact, 
as a general proposition, there was almost none of the dis- 
ease outside of Washington County. The scattering cases 
that occurred in Windsor and Franklin Counties might be 
described, under the old but vague classification, "sporadic" 
cases. 

The following table gives the number of cases in each 
county by months on the two sides of the state. 



POLIOMYELITIS IN VERMONT— 1916-1917 173 



Counties 5«^3>3 3 3 , 3 £ £ £ ,£ r° 



East 










V 


>> 


bo 




+j 


3 
i— > 


3.. 


< 


0> 

1 


o 


1 


1 




2 
1 


1 


44 


32 


35 

2 


15 


5 




2 


3 


8 





Caledonia 1 1 

Essex 

Orange 112 4 

Orleans 11 2 

Washington 6 44 32 35 15 5 137 

Windham 2 2 

Windsor 2 3 8 13 



Totals 6 45 35 40 27 6 159 



West 

Addison 1 1 

Bennington 

Chittenden 11 2 

Franklin 1 3 2 17 

Grand Isle 

Lamoille 2 2 

Rutland 



Totals 20000014221 12 

It is a general observation that infantile paralysis spreads 
along lines of human communication. Reference has been 
repeatedly made to the mountain barrier dividing this state. 
This barrier is very evident from the line of the Winooski 
River south. Cross state communication north of this river 
is freer. This explains the comparatively equal distribution 
of the disease between the east and west sides in 1914 — an 
epidemic general over the northern portion of the state. 
This has never occurred in the southern half of the state 
where the mountains form a real barrier to human inter- 
course. An outbreak in Addison, Rutland and Bennington 
Counties would not extend to Windham, Windsor, Orange 
or Washington, or vice versa. Thus with 159 cases this year 
on the east of the Green Mountains, there were only 12 on 
the west. In 1910, the east side had 51; the west, 18; in 
1911, the west side had 22, the east, 5 ; in 1913, the east side 
had 40, the west, 7 ; and in 1916, the west had 53, and east, 







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POLIOMYELITIS IN VERMONT— 1916-1917 175 

11. During the past eight years, for which we have records, 
there have been altogether 23.7 cases per 1000 population 
on the east side of the state, and 19.5 per 1000 on the west. 

The first epidemic in the state, and indeed in this country, 
occurred on the west side of this state. The western side of 
Vermont is open chiefly to invasion by infection from New 
York State and the Province of Quebec. No direct connec- 
tion with outside epidemics, however, has ever been traced, 
except in 1916. The eastern side of the state may naturally 
be invaded from Massachusetts and other New England 
points, as well as Quebec. Here, too, only one such connec- 
tion has been traced with certainty, viz : the 1910 outbreak 
in the Connecticut Valley, which was a direct extension 
from Springfield, Mass. 

In recent years, however, the eastern side of the state has 
suffered somewhat more than the western, as shown by the 
above figures. 



PREVENTIVE MEASURES 

On account of the unusual number of cases being reported 
from Barre Town and Montpelier (unusual for so early in 
the summer), the Board met in Montpelier, June 24, and 
after a conference with the local Board of Health and Mayor 
and the health officers of some of the neighboring towns 
advised that all public gatherings in the city be discon- 
tinued for the present, and that restrictions be put upon 
children patronizing ice cream or soda counters. These re- 
strictions were recommended for Montpelier, Barre (Town 
and City) and Waitsfield. 

Cases continuing to appear in these towns, as well as 
others, especially in Washington County, a meeting of the 
Board was held in Burlington, July 17, at which Governor 
Graham was present. At this meeting the following order 
was made : — 



176 INFANTILE PARALYSIS IN VERMONT 

Vermont State Board of Health 

Burlington, July 17, 1917. 

To date we have had in the state 68 cases of infantile 
paralysis this year. This is a greater number of cases than 
we have had any year during the last five years with one 
exception. Sixty-one of these cases and six deaths have 
occurred since June 16. These cases with three exceptions 
have been confined to Washington County. There are good 
reasons for hoping that this outbreak may be checked at 
this time. In past years we have had reason to think that 
large general gatherings of people from many towns have 
distributed this infection. August and September in past 
years have been our worst months as far as this disease is 
concerned. 

In view of these facts the attention of local boards of 
health is hereby called to Act No. 194 of the Laws of 1917 
and such boards are directed to make and enforce regula- 
tions in the several towns whenever local conditions require 
such action. When one or more cases develop in any town 
the local board of health should take action either prohibit- 
ing all public gatherings or excluding all children under 16 
years of age from such gatherings, also from lunch, soda 
water and ice cream counters and other public eating and 
drinking places. 

It is hereby ordered that no fairs, Chautauquas, street 
carnivals or circuses be held in the State of Vermont until 
further notice. 

By order of the State Board of Health, 

Charles F. Dalton, 

Secretary. 

As stated in the prelude to this order, it had been strong- 
ly suspected in former years, especially in 1914, that the 
disease was spread by large general gatherings of people, 
which include children. For this reason, and the further 



POLIOMYELITIS IN VERMONT— 1916-1917 177 

reason given in the order, that August and September were 
months in which we had had the most of this disease in 
former years, it seemed the part of prudence, indeed, im- 
perative, that such general gatherings be dispensed with 
this year. 

There was no serious objection made on the part of any 
one, as far as known, to the enforcement of this order, ex- 
cept by a company, known as the "Community Chautauqua." 
Several "Chautauquas" had made contracts in various parts 
of the state for meetings. The "Community Chautauqua" 
had apparently the largest number of these contracts. Em- 
ploying able counsel, this Company secured, through United 
States District Judge H. B. Howe, an order restraining the 
State Board of Health and certain local boards from enforc- 
ing this order, pending a hearing for a temporary injunc- 
tion. A hearing was held at St. Johnsbury, July 30, before 
Judge C. M. Hough of New York City. The decision of 
Judge Hough is of sufficient importance, from a public 
health, as well as legal standpoint, so that it is hereby given 
in full: — 

United States District Court 
District of Vermont 

Community Chautauqua, Inc. vs. Charles S. Caverly, Et Al 

Motion to continue restraining order and for preliminary 
injunction. 

Action to restrain the enforcement of an order of the 
Board of Health of the State of Vermont, — order dated July 
17, 1917, and directing that "no fairs, Chautauquas, street 
carnivals or circuses, be held in the State of Vermont until 
further notice." 

Plaintiff owns and gives that form of entertainment 
known as a Chautauqua and has made a large number of 
contracts to give such entertainments in the State of Ver- 
mont during the present summer season. 



178 INFANTILE PARALYSIS IN VERMONT 

This order of the Board of Health prevents all persons 
from attending these performances and so in effect prevents 
the performances themselves. It has been assumed by the 
parties that the order in question not only does this but 
terminates the contracts themselves, or so abrogates them 
as to inflict upon plaintiff a total loss of the amounts ex- 
pended in preparing to give such entertainments in pur- 
suance of said contracts. 

It was admitted that the reason for the order of the Board 
of Health was, and is, as set forth in the order itself, to 
wit; a belief that "large general gatherings of people — 
have distributed" the infection of infantile paralysis. 

It was not alleged in the bill, nor urged in argument, that 
the defendants (who are all the health officers in the State 
in regions in which it was intended to hold Chautauquas) 
were actuated by any malice or intended, wantonly or other- 
wise, to injure plantiff, but solely by their own opinion of 
what is desirable from a sanitary and prophylactic stand- 
point. 

Dunnett & Shields for plaintiff. 

Herbert G. Barber, Attorney General of Vermont for de- 
fendants. 

Hough, C. J. The sole ground of jurisdiction set up in 
this bill is diversity of citizenship and the prayer of the bill 
is that defendants "be restrained from making or enforc- 
ing any order designed to prevent the performance of the 
contracts" of plaintiff to give Chautauquas in Vermont. 

The reason of the bill and this prayer is that the order 
in question "unjustly discriminates against the plaintiff and 
against the entertainments to be given by the plaintiff." 

It appears from argument, however, that the discrimina- 
tion complained of is not thought to rest upon any personal 
prejudice against plaintiff or its entertainments but upon 
the proposition outlined in the bill, asserted in affidavits, 
and presented in arguments, that public gatherings in- 



POLIOMYELITIS IN VERMONT— 1916-1917 179 

duced by an intellectual entertainment such as a Chautau- 
qua do not tend to spread infection and that such is the 
opinion of some doctors. 

Thus the question primarily presented to this court is 
whether the professional opinion of a board of doctors, hon- 
estly exercised, shall be overturned by the chancellor on the 
ground that it is "unreasonable." 

It is said that State vs. Speyer, 67 Vt. 502, upholds this 
view. 

Undoubtedly there are cases (and the case cited is one of 
them) wherein police regulations cannot be held justifiable 
"unless there are reasonable grounds for a belief that the 
necessary protection of the public health" requires their 
passage. This is a simple doctrine and means no more than 
that it is the duty of the court to examine into the facts of 
every case and if a responsible, honest and presumably 
reasonable body of professional opinion is found on the side 
of the regulation, it is the duty of the Court to uphold it 
even though the chancellor should entertain the view of pro- 
fessional dissidents. 

The point is not whether the court agrees with the pro- 
fessional conclusion of a body of doctors, or engineers, or 
clergymen, but whether it is evident that the professional 
view is a reasonable view for men of the proper profession 
to entertain. They may be wrong, but is there any reason- 
able probability of their being right? If that question is 
answered in the affirmative, the professional regulation 
cannot be said to be unreasonable, — as a matter of law. This 
is the view taken in the State vs. Morse, 84 Vt. 387, and the 
whole matter is covered by the remarks of Holmes, J., 
quoted (at page 397) from Laurel Hill Cemetery vs. San 
Francisco, 216 U. S. 358. 

I am, therefore, not called upon to come to any conclusion 
as to whether the propagation of poliomyelitis is actually 
assisted by crowds, but I am persuaded; (1) that a very 



180 INFANTILE PARALYSIS IN VERMONT 

responsible body of professional opinion, is that way; (2) 
that the Vermont Board of Health shares that view; (3) 
that it has just as much right to entertain that view as I 
have to entertain an opinion upon a point of law; and (4) 
that such a point of view cannot be held to be unreasonable. 

Although the bill does not in terms rest upon any consti- 
tutional point, such point was necessarily presented. 

Thus the bill prays to have certain contracts preserved, — 
preserved from what? From an exercise of the police power 
of the State in accordance with a responsible body of pro- 
fessional opinion. 

An act of the Legislature thus impairing a contract is 
not unconstitutional. Manigault vs. Ward, 123 F. R., 707; 
affirmed 199 U. S. 473. 

That the prevention of disease, or its spread, by any 
means based on responsible medical opinion is a competent 
and constitutional exercise of police power is a proposition 
so plain as to scarcely require citation. 

The Legislature might have said that there should be no 
gatherings at all except by license (Davis vs. Common- 
wealth, 167 U. S. 43) and discrimination or classification is 
frequently based not on medical opinion but merely on mat- 
ters of taste. Of this, perhaps the best illustrations are the 
"Ice cream cases," of which Powell vs. Pennsylvania, 127 
U. S. 678 was the first (and the last is as yet unreported). 

That the Board of JTealth acted within its statutory au- 
thority is, I think, pk in from Chapter 194 Vermont Laws 
of 1917 which explicitly authorizes local health officers (such 
as most of the defendants herein) to "forbid and prevent 
the assembling of people in any place, when the State Board 
of Health deems that the public Health and safety so de- 
mand." 

This is not a delegation of law making authority, for the 
Assembly laid down the law but entrusted its application 



POLIOMYELITIS IN VERMONT— 1916-1917 181 

to medical men who would be presumed better informed as 
to local conditions. 

If this matter be regarded as one of local law, only cog- 
nizable in the United States Courts because of diversity of 
citizenship, I think the matter fairly within the ruling in 
state vs. Morse supra ; if (looking beyond the form of plead- 
ing) other questions be considered, no constitutional rights 
of plaintiff have been invaded. Therefore, the application 
cannot be granted, — a result the more willingly reached be- 
cause the papers presented (especially the results of polio- 
myelitis observations in Vermont for some years past) con- 
clusively show to me that the moves of this mysterious 
disease are so little understood that any honest medical ef- 
forts to effect its extermination should meet with assistance 
rather than hostility. 

The restraining order is dissolved and preliminary in- 
junction denied. 

A motion to amend the bill was made at the hearing and 
no objection made thereto. If the form of the amendment 
is transmitted to me through the clerk of the Court, it will 
be formally allowed so far as can now be seen. 

July 30, 1917. C. M. Hough, 

(Endorsed) Filed August 3, 1917. Cir. Judge. 

Frederick S. Platt, Clerk. 

United States of America, District of Vermont 

I, Frederick S. Platt, Clerk of the District Court of the 
United States, within and for the District of Vermont, here- 
by certify that the foregoing is a true and complete copy of 
the original opinion and order made, filed and docketed in 
cause No. 47 on the Equity Docket of said Court, entitled : 

Community Chautauquas, Inc. 

vs. 

Charles S. Caverly, Et Al. 



182 INFANTILE PARALYSIS IN VERMONT 

Witness My Hand, as such clerk and the seal of said Court, 
at the office of the Clerk of said Court, in the City of 
Rutland, in said District this 18th day of March, A. D., 
1918. 

(Signed) Frederick S. Platt, 

Clerk. 

On the blanks used in collecting data of this outbreak, 
there is this question : Has patient been to any large public 
gathering? If so, place and date. 

While this question is often unanswered, the answers 
given show that fourteen children attended such public 
gatherings within two weeks before being taken sick. Nine 
of these were outdoor functions, such as Decoration Day or 
Fourth of July celebrations or school picnics, and five had 
attended picture shows. 

Meantime many towns and cities in the state had taken 
advantage of an Act of the last Legislature, which author- 
ized Health Officers to "order churches, schools, and all 
places of public entertainment to be closed" ; and to "forbid 
and prevent the assembling of people in any place, when 
the State Board of Health deems that the public health and 
safety so demand." 

The same Act provided that "the local Board of Health 
in a town or city may make and enforce Rules and Regula- 
tions in such town or city, relating to the protection of the 
public against contagious and infectious diseases and the 
cause, development and spread of any disease, provided 
such Rules and Regulations have the approval of the State 
Board of Health." 

Some of these towns were Barre City, Braintree, Shel- 
burne, Woodbury, Northfield, Richmond, Randolph, Rutland 
City, Duxbury, East Montpelier, Greensboro, Bradford, 
Brookfield, and Weathersfield. The regulations adopted by 
these towns were quite similar. A sample is herewith given : 



POLIOMYELITIS IN VERMONT— 1916-1917 183 

Braintree, Vermont, July 17, 1917. 
In accordance with No. 194 of the laws of 1917, the local 
board of health of the town of Braintree hereby makes the 
following rules and regulations against the cause, develop- 
ment and spread of infantile paralysis. 

1. Children under 16 years of age entering this town 
from any town or city where the disease is known to exist 
shall be subject to quarantine for the period of two weeks. 

2. Children under 16 years of age shall be excluded from 
all public gatherings held indoors or outdoors, including 
churches, Sunday schools, theatres, places of amusement 
and all public gatherings of any kind. 

3. Children under 16 years of age shall not be served at 
any ice cream counter, soda water fountain, restaurant or 
any place where food or drink is sold to be consumed on 
the premises, exception being made to hotels. 

These regulations shall continue in force until vacated by 
a written order signed by the Secretary of the State Board 
of Health or the local health officer. 

Local Health Officer. 
Approved by the State Board of Health. 

Secretary 

To 

You are hereby notified of the above rules and regula- 
tions and ordered to observe the same. 

Signed 

Health Officer for June, 1917 

While, as has been stated, the disease, infantile paralysis, 
is undoubtedly of low contagiousness, and not at all com- 
parable in this respect with such diseases as measles or 
smallpox, there is no doubt that the main, if not the only, 
method of distributing the disease is through human agen- 
cies. Human beings, rather than things, animals, or insects 
are without any doubt the chief distributors of the disease. 



184 INFANTILE PARALYSIS IN VERMONT 

Furthermore, it is well established that not only frankly 
paralytic cases, and the so-called abortive cases, but also 
healthy persons may harbor and distribute the virulent 
organisms of the disease. 

If these facts are facts, they place a distinct duty upon 
health officials ; that duty involves the prevention of general 
gatherings of human beings in the presence of this disease 
in epidemic form. The public gatherings directly affected 
by the original order of the State Board were such as would 
be likely to attract people from widely separated districts. 
Washington County, the center of the disease this year, is 
in the center of the state. There is probably not a county 
in the state, in which, if large meetings of any kind were 
held, there would not be representatives from this county. 

At the middle of July, 1917, there were over 50 cases of 
this disease, and confined almost exclusively to this county. 
The restrictive measures adopted by the State Board and 
by local boards in various towns were apparently justified. 
Reference to the map, showing the distribution of the dis- 
ease through the year, seems to prove this. The disease in 
epidemic form was confined to Washington County. Scat- 
tering, "sporadic," cases occurred in several counties; but 
these are not only such as are quite likely to occur in any 
year, but there was nowhere else anything approaching epi- 
demic conditions. 

Among all the towns, excepting Barre City, that took ad- 
vantage of the statute authorizing their local boards to 
make and enforce Rules and Regulations against contagious 
and infectious diseases in this outbreak, there were only 
three cases of the disease after the promulgation of such 
Regulations. 

The experience of Barre City in this epidemic is inter- 
esting. As has been stated, this city, which is much the 
largest place in Washington County, was surrounded by the 
disease in June; Barre Town and Montpelier having each 



POLIOMYELITIS IN VERMONT— 1916-1917 185 

many cases from the middle of that month. A single case, 
which was probably of at least two weeks' standing, was 
discovered in Barre City, July 6. There were no more cases 
in that city for ten days. It cannot be stated with any cer- 
tainty whether the first of the cases in the real epidemic in 
that city were any of them traceable to this case that went 
undiscovered until July 6. 

Barre City had early taken precautions recommended by 
the State Board of Health on June 24, at the meeting held 
in Montpelier. These regulations had been quite carefully 
enforced and it was a matter of comment at the time that 
Barre City was escaping the general outbreak affecting sur- 
rounding towns. This was especially noticeable because of 
the intimate relations existing, socially and commercially, 
between Montpelier and Barre. Closely related in this way 
and with free communication by way of trolley, steam cars, 
and highway, it was naturally expected that Barre City 
would have cases of the disease early. When finally it be- 
came evident that this city was sharing in the epidemic of 
the surrounding towns, the local Board of Health adopted 
the following stringent Regulations : 

Barre, Vermont. 
In accordance with No. 194 of the laws of 1917, the local 
board of health of Barre, Vt., hereby makes the following 
regulations against the cause, development and spread of 
infantile paralysis. 

1. All public gatherings shall be prohibited, whether they 
are to be held indoors or outdoors, including schools, Sun- 
day schools, churches, theatres, picnics, ball games, first 
class saloons, lodge meetings, club rooms, pool rooms, soda 
fountains and ice cream parlors, if ice cream is to be con- 
sumed on premises. 

2. All children under 16 years of age shall be kept on 
their own premises, except those who are working. 



TEMPERATURE CHART. Northfield, Vt., 1916 
Normal — 35 Years — ■■— ^ ■ 
Mean-— 1916 





Jan. 


Feb. 


Mch. 


April 


May 


June 


July 


Aug. 


Sept. 


Oct. 


Nov. 


Dec. 


70 


















































60 




















































50 




















































40 






























■ 






















30 




















































20 


















































10 


















































! 



70 
60 
50 
40 
30 
20 
10 



TEMPERATURE CHART. Northfield, Vt., 1917 

Normal — 36 Years 

Mean— 1917 

Jan. Feb. Mch. April May June July Aug. Sept. Oct. Nov^ Dec. 















ir^r* 






















<? 


^-■^v. 


n\ 


















y 


/ 






















/ i 


f 












i 














































































































































* 








































































* 



















































POLIOMYELITIS IN VERMONT— 1916-1917 187 

To be in force until vacated by written order signed by 
Secretary of Board of Health. 

Thereafter only 16 cases were reported in that city. Some 
objection was raised to the somewhat drastic Regulations 
referred to. An injunction was secured from a Judge of 
the Superior Court, restraining the local Board of Health 
from interfering with the conduct of its business, by one 
firm. A hearing was promptly held and the injunction dis- 
solved. Thereafter, the Regulations of the local board were 
strictly and generally enforced. Barre City's comparative 
exemption from the disease is undoubtedly largely due to 
the stringent measures adopted by the local board. 

weather: 1916 and 1917 

Heretofore, the waves of infantile paralysis in Vermont 
have generally coincided with dry weather. High tempera^ 
tures have not been noticeable. 

The United States Weather Bureau, located at Northfield, 
is in the immediate neighborhood of the epidemic of 1917. 
It will be observed by the following charts that the July and 
August temperatures in each year were somewhat above 
the normal, but that the temperatures for the early sum- 
mer months, May and June, and in the case of 1917, April 
also, are below the normal. 

The mean temperature for the year 1916 shows a 0.3 de- 
parture; and, in 1917, a 3.2 departure. These two years, 
therefore, especially 1917, could not be considered hot years. 
March had a mean temperature of 26°. A recent winter out- 
break in West Virginia in December and January occurred 
with a mean temperature for the period of 32. (Draper.) 

The chart on page 189, which is a continuation of the one 
published in the report for 1914 and '15, shows graphically 
the precipitation departures for the series of twelve years. 
This chart was prepared to study the relation which our 
infantile paralysis outbreaks bore to dry seasons. It in- 



188 INFANTILE PARALYSIS IN VERMONT 

eludes only the infantile paralysis months of the first eleven 
years. The dotted lines show the rain fall departures; the 
part above zero line representing dryness, and the part be- 
low the zero line representing the excess of rainfall. Both 
1916 and 1917 were dry years. In 1916, this was especially 
true of March, August and October; whereas, May, June 
and July were wet months. The figures for 1917 show a 
minus departure, though less than 1916. June and October 
were wet, whereas July, August, September and November 
were dry. On the whole, it may be said from the data ob- 
tainable from the Weather Bureau that "seasonal dryness" 
in these two years was a fact. While this is a fact, it must 
be said that the coincidence of the severity of our outbreaks 
of this disease and dry seasons is not striking. 

POLIOMYELITIS WORK DONE BY THE BOARD UNDER 
THE SPECIAL FUND 

The philanthropic work, anonymously supported, to which 
reference was made in the last Biennial Report of this 
Board, has been continued during 1916 and 1917. The 
Research Laboratory has been maintained and the after- 
treatment of the cases has gone on — both with highly grati- 
fying results. 

Laboratory 
Carrying out the original plan of the anonymous donor, 
a portion of the fund was set aside for laboratory purposes. 
In order that the entire attention of the laboratory should 
be concentrated on poliomyelitis, a separate organization 
was made and the laboratory established with the coopera- 
tion of the University. The laboratory occupies four rooms 
on the ground floor of the College of Medicine and has an 
animal room on the roof. The equipment includes special 
appartus for diagnostic work and for investigation of filter- 
able viruses. 



190 INFANTILE PARALYSIS IN VERMONT 

Personnel 

The Advisory Board consists of Dr. Charles S. Caverly, 
President of the State Board of Health ; Dr. Simon Flexner, 
Director of the Rockefeller Institute for Medical Research 
and Dr. B. H. Stone, Director of the Laboratory of Hygiene 
of the State Board of Health. 

Dr. Harold L. Amoss of the Rockefeller Institute for 
Medical Research has directed the activities of the labora- 
tory. Dr. Edward Taylor of Alabama has continued direc- 
tor of the Research Laboratory. 

The laboratory has three functions: first, differential 
diagnosis of cases of poliomyelitis; second, the specific 
treatment of cases; third, investigations to add to our 
knowledge of the disease. 

Diagnostic Work 
On early diagnosis depends not only success in treatment 
but the greater problem of prevention. Amoss and Chesney 
have shown that cases of poliomyelitis treated with human 
convalescent serum before the forty-eighth hour of illness 
have greater chances of recovery. Persons coming into 
contact with active cases of the disease may be regarded as 
potential carriers, for it has been shown that persons ap- 
parently well may harbor the virus or active infecting agent 
in their nasal secretions. It becomes imperative, therefore, 
to establish early diagnosis. Early diagnosis, even before on- 
set of paralysis, can be made, but since there is no definite 
biological reaction by which a diagnosis can be made it may 
be an exceedingly difficult task. The chemical bacterio- 
logical and cytological examinations of the spinal fluid give 
invaluable assistance in diagnosis but the results must be 
interpreted in the light of clinical examination. Accurate 
differential diagnosis is best made by the physician who has 
both laboratory and clinical training at his command. Since 
the average physician is not constantly called upon to diag- 



POLIOMYELITIS IN VERMONT— 1916-1917 191 

nose poliomyelitis, it becomes advisable to centralize the 
responsibility of diagnosis in such a laboratory. During the 
summer season, most of the time of the laboratory staff was 
occupied in diagnoses. During 1915, 1916 and 1917, many 
cases were visited and 281 diagnosed as poliomyelitis. 

In addition to the value of diagnostic activities already 
referred to, the educational value of such a method should 
be borne in mind. Clinics have been held in various parts 
of the state and to more than 125 physicians have been de- 
monstrated lumbar puncture and method of examination 
of the fluid, together with the methods of clinical examina- 
tion. This part of the work of the laboratory has undoubt- 
edly resulted in a decrease in the number of cases from the 
expectant rate. During 1914, there were 306 cases ; in 1915, 
44 cases ; in 1916, 64 cases, the time of the great New York 
epidemic. As one result of the laboratory, several localized 
epidemics were apparently stopped with the appearance of 
the first series of contact cases. Due to accurate quarantine, 
no second contact cases occurred. 

Treatment 

With an additional fund of $1,000 for expenses con- 
tributed by Dr. F. S. Lee of New York, it was possible in 
1916 to pay convalescent patients for serum to be used in 
the treatment of acute cases. It became the duty of the 
laboratory to collect the serum and to administer it at the 
homes of new patients throughout the state. During 1916, 
19 patients were thus treated. Of these, two died and in 
two the infection was not stayed and in one case no im- 
provement observed. Marked improvement, however, was 
obtained in fourteen of the cases treated. These cases have 
been reported in the New York Medical Journal for May, 
1917, by the Director of the Laboratory, Dr. Taylor. 

During 1917, 11 cases were treated, with two deaths. In 
the two years 1169 c.c. of serum were administered. (1916, 
779 c.c; 1917, 390 c.c.) 



192 INFANTILE PARALYSIS IN VERMONT 

The cases were treated with large amounts of serum in- 
traspinally and intravenously, according to the method of 
Amoss and Chesney. It was found that the serum remained 
potent after preservation with 0.25 per cent trikesal at the 
temperature of the ice-box for at least nine months. The 
serum should, however, be used as early as possible after 
withdrawal from the patient. 

The results obtained confirm those of previous workers 
and demonstrate the practicability of carrying on such 
treatment in the field. 

Research 

With the yearly recurrence of cases within the state, ideal 
opportunity offered itself for investigation. Many workers, 
some with large endowments, have been engaged in research 
in poliomyelitis over a number of years. Moreover, the only 
experimental animal thus far found to be susceptible to in- 
fection with poliomyelitis is the monkey, making experi- 
mental work very expensive and slow. In spite of these ap- 
parent difficulties the results of two years' work have been 
unexpectedly gratifying. Two reports published in the 
Journal of Experimental Medicine have contained note- 
worthy contributions to our knowledge of the disease. 

Naturally, the investigator's endeavors were directed 
along lines which promised practical results. Among the 
first studies was the improvement of methods for the de- 
tection of carriers of poliomyelitis. Epidemiological obser- 
vations first by Wickman pointed certainly to the existence 
of human carriers who showed no clinical evidence of fur- 
ther invasion of the virus. Swedish and American observers 
have proven experimentally by the inoculation of filtered 
nasal secretions from contacts that healthy persons some- 
times carry the virus, but out of many attempts only a 
small percentage of the positive results were obtained. This 
may be explained by the natural difficulties attending the 



POLIOMYELITIS IN VERMONT— 1916-1917 193 

isolation of the virus from such sources. Monkey inocula- 
tion is the only method at our command for detecting the 
virus, and virus of human origin possesses relatively low 
infective power for monkeys. Moreover, the virus is usually 
present in the nasal secretions in small amounts and 
thorough rinsing of the nasal cavities results in relatively 
large amount of fluid. This fluid is contaminated by many 
organisms, usually found in the nose, and which must be 
removed by filtration before injecting into the monkey. 
Route of infection may be induced in a monkey by the 
smallest amount of virus when the direct intracerebral 
route is used. From four to six c.c. of fluid can be safely 
injected into the monkey brain but the nasal washings 
from a single person may be fifteen to twenty times as 
much. Efforts to overcome some of these resulted in a 
method, roughly, five times as sensitive as the former meth- 
ods used. The improved method takes advantage of the 
solubility of mucin in sodium bicarborate solution. After 
adding sodium bicarborate and shaking with glass beads, 
the fluid is filtered and rapidly reduced in volume at 35 deg. 
C. under reduced pressure. The residue is dialyzed and in- 
jected intracerebrally into the monkey. One of the particu- 
lar points is the rapid handling of the nasal secretions after 
collection. 

In testing the method on controls, it soon becomes evident 
that still another factor operated to decrease the number of 
positive results if washings from more than one person 
were mixed. Sterilized nasal secretions from various per- 
sons do not react alike when incubated with the virus. The 
results of 62 experiments show that nasal washings possess 
definite power to neutralize the active virus of poliomyeli- 
tis. This contribution of our Research Laboratory is one 
of the most important additions yet made to our knowledge 
of infantile paralysis. This power of naso-pharyngeal muc- 



194 INFANTILE PARALYSIS IN VERMONT 

cus to neutralize poliomyelitis virus is not absolutely fixed 
but is subject to fluctuation in a given person. 

Apparently, inflammatory conditions of the upper air 
passages tend to remove or diminish the power of neutral- 
ization, but irregularities have been noted even in the ab- 
sence of these conditions. These experiments suggest that 
the nasal washings of children possess the neutralizing 
power less than those of adults and also that the neutraliz- 
ing power is diminished in the summer months. The neu- 
tralizing substance is water-soluble and appears to be due 
to salts ; it appears to be slightly changed by heat and does 
not depend upon the action of mucin, as such. Experiments 
are under way to determine definitely whether seasonal 
variations occur and to determine the distribution of the 
neutralizing power among definite groups of persons. This 
neutralizing action of the nasal secretions is suggested as 
one of the factors determining whether or not persons ex- 
posed become carriers of the disease, if they have other 
mechanisms of defense or contract the disease in the ab- 
sence of other means of defense. 

The second contribution from the laboratory deals with 
the mode of infection of poliomyelitis. The clinical observa- 
tions of the Swedish observer Wickman strongly suggest 
that the microbic cause of poliomyelitis may be transmitted 
by apparently healthy carriers. The production of experi- 
mental poliomyelitis in the monkey by the injection of nasal 
secretions from persons who had been in contact with cases 
of the disease definitely established the carriage of the 
virus. But the observations by Flexner and Lewis, and Kling 
and Peterson have been too few to convince many observers 
of the validity of the theory. During 1917, the Research 
Laboratory studied the prevalence of carriers in Vermont. 
The report of examinations of a family of four children 
published in the Journal of Experimental Medicine forms 
an instructive illustration of the mode of infection of the 



POLIOMYELITIS IN VERMONT— 1916-1917 195 

disease as brought out by clinical and experimental study. 
This study establishes more firmly the carriage method and 
describes for the first time the occurrence of two carriers 
in the same family and carriage of the virus during the in- 
cubation period of the disease. A family group containing 
four children, all of whom showed in varying degree symp- 
toms of poliomyelitis, is described. The source of infection 
and periods of incubation have been followed. Two of the 
children were proven by inoculation tests to carry the virus 
of poliomyelitis in the nasopharynx. Of these, one was de- 
tected to be a carrier after recovering from a non-paralytic 
attack of the disease, and the other was discovered to be a 
carrier about five days before the initial symptoms, attended 
later by paralysis, appeared. The original case from which 
the three others took origin was fatal; the youngest child, 
after quite a severe onset, was treated with immune serum, 
and made a prompt and almost perfect recovery. The naso- 
pharyngeal secretions of two of the cases, taken one month 
after the attack, proved incapable of neutralizing an active 
poliomyelitic virus. 

The proposition is presented that every case of poliomye- 
litis develops from a carrier of the microbic cause, or virus, 
of poliomyelitis. 

The laboratory is now studying the question of selective 
communicability. 

TREATMENT OF RESULTANT PARALYSIS 

"The Vermont Plan" 
Dr. Robert W. Lovett, Orthopedic Surgeon to the Chil- 
dren's Hospital, Boston, and Professor of Orthopedic Sur- 
gery at Harvard Medical School, still directs this work. Dr. 
Lovett was assisted at his earlier clinics by his assistant in 
private work, Miss Wilhelmine G. Wright. He began his 
clinics in December, 1914. These clinics were repeated the 
following summer (1915) ; also in 1916 and 1917 in the 



196 INFANTILE PARALYSIS IN VERMONT 

summer. They were held at points in the state which seemed 
best adapted to accommodating the patients, viz., Burling- 
ton, Rutland, Montpelier, Barton and St. Albans. These 
clinics were held at the local hospitals, except in the case of 
Barton, which has none. The medical profession generally 
and nurses were always invited and many always were 
present. Besides Miss Wright, Dr. Lovett had the assistance 
of Miss Janet B. Merrill, Miss Helen King and Miss Rebecca 
Selfridge, all trained under his direction for this special 
work, at his later clinics. These women were all employed 
later for supervision work in the field. 

Reference was made in the last report to a method of 
measuring muscular strength by means of the spring bal- 
ance, which was devised for and first tested on these Ver- 
mont cases. This method, devised by Dr. Lovett, in conjunc- 
tion with Dr. E. G. Martin of the Physiological Department 
at Harvard has proven of much practical value. 

This plan of holding free public clinics for the maimed 
children, following an outbreak of Infantile Paralysis, has 
been since adopted in other states, notably New York, after 
the 1916 epidemic, and has become known as "The Vermont 
Plan." 



Census of Cases Seen at Various Clinics 

Number of cases seen at the Dec, 1914 and Jan., 1915 
clinics, 212: 

Burlington 47 

Montpelier 41 

Barton 45 

Rutland 41 

St. Albans 38 



Total cases 212 



POLIOMYELITIS IN VERMONT— 1916-1917 197 

Number of cases seen at the July, 1915 clinics 122 

Burlington (18 new,— 19 Jan., 1915) 37 

Montpelier (7 new, — 10 Jan., 1915) 17 

Barton (16 new,— 12 Jan., 1915) 18 

Rutland (12 new,— 11 Jan., 1915) 23 

St. Albans (7 new,— 20 Jan., 1915) 27 

Total cases 122 

Number of cases seen at the July, 1916 clinics 108 

Burlington 34 

(12 new, 4 Jan., 1915, 2 July, 1915, 16 
Jan. and July, 1915.) 

Montpelier 10 

(2 new, 5 Jan., 1915, 1 July, 1915, 2 Jan. 
and July, 1915.) 

Barton 21 

(12 new, 4 Jan., 1915, Jan. and July, 
1915.) 

Rutland 23 

(7 new, 5 Jan., 1915, 4 July, 1915, 7 Jan. 
and July, 1915.) 

St. Albans 20 

(3 new, 3 Jan., 1915, 3 July, 1915, 11 
Jan. and July, 1915.) 

Total cases 108 

Number of cases seen at the August, 1917 clinics 186 

Burlington 45 

(21 new, 5 Jan., 1915, 4 July, 1915, 3 
July, 1916, 2 Jan., 1915 and July, 1916, 
and 10 all clinics.) 



198 INFANTILE PARALYSIS IN VERMONT 

Montpelier 56 

(44 new, 2 Jan., 1915, 2 July, 1915, 1 

July, 1916, 6 Jan. and July, 1915, 1 Jan. 

1915 and July, 1916.) 
Barton 25 

(7 new, 4 Jan., 1915, 1 July, 1916, 3 Jan. 

and July, 1915, 3 Jan., 1915 and July, 

1916, and 7 all clinics.) 
Rutland 38 

(16 new, 2 Jan., 1915, 2 July, 1915, 2 

July, 1916, 2 Jan. and July, 1915, 3 Jan. 

1915 and July, 1916, and 8 all clinics.) 
St. Albans 22 

(2 new, 2 Jan., 1915, 2 July, 1916, 4 Jan. 

and July, 1915, 2 Jan., 1915 and July, 

1916, 1 July 1915 and July, 1916, and 9 

all clinics.) 



Total cases 186 

Total number of cases seen at all the clinics 628 

Individual cases 392 



Summary of Results Obtained — among the Individual 

Cases Seen in 1914, 1915 and 1916 

(Embracing cases supervised by Miss Merrill and Miss King, outside 
of Washington County.) 

Followed treatment 96 

Improved 74 

No change 3 

Worse 

Complete recovery 5 

Practical recovery 14 

96 

Followed treatment irregularly 37 

Improved 18 

No change 16 

Worse 3 

Complete recovery 

Practical recovery 

37 



POLIOMYELITIS IN VERMONT— 1916-1917 199 

Number who did not follow treatment 50 

Improved 6 

No change 20 

Worse t 23 

Complete recovery 

Practical recovery 1 

Total 183 

1917 Cases, Exclusive of those Supervised by Miss Selfridge 
in Washington County 

Followed treatment 102 

Improved 82 

No change 5 

Worse 

Complete recovery 4 

Practical recovery 11 

102 

Followed treatment irregularly 29 

Improved 16 

No change 12 

Worse 1 

Complete recovery 

Practical recovery 

29 

Number who did not follow treatment 37 

Improved 6 

No change 22 

Worse 8 

Complete recovery 

Practical recovery 1 

37 
Total 168 

183 
351 

To obviate a common error, in practicing massage, using 
electricity, allowing walking or other natural exercises too 
early, Dr. Lovett, after his examination of a large number 
of recent cases in Washington County in 1917, suggested 
that many of these be placed under early and continuous 
supervision. Miss Selfridge was given charge of this work, 
and saw these cases in Barre City, Montpelier and Waits- 
field twice a week, supervising the training of the weak 
muscles. 



200 INFANTILE PARALYSIS IN VERMONT 

Her report (to May, 1918) follows: — 

Number followed treatment regularly 41 

a. Complete recovery 12 

b. Practical recovery 9 

c. Improved 18 

d. No change 2 

e. Worse 

41 
Number followed treatment irregularly 31 

a. Complete recovery 1 

b. Practical recovery 4 

c. Improved 23 

d. No change 3 

e. Worse 

31 

The gratifying results as indicated by these figures sug- 
gest possibilities in the future management of these cases, 
of greatly minimizing the permanent paralysis. These re- 
sults show the importance of early and careful supervision. 
This supervision simply ensures rest of the child and espe- 
cially the affected limbs or muscles until muscle-training 
can be safely begun. It then directs this training. 

Besides the advice given these cases at the clinics and the 
field work done by these nurses, many cases have been 
placed in Vermont hospitals, or the Children's Hospital in 
Boston for surgical treatment, the expense being met out of 
our "Special Fund." 

During the last two years, 114 pieces of apparatus, braces, 
corsets, splints, etc., have been provided for children in the 
state. Since the beginning of this work in 1914, 168 such 
pieces of apparatus have been secured and applied to these 
cases. The expense for this has been met in part by the 
patients and their friends and, where necessary, has been 
paid from our Special Fund. 



THE TREATMENT OF INFANTILE 
PARALYSIS 

Preliminary Report Based on a Study of the 
Vermont Epidemic of 1914* 

R. W. Lovett, M.D., Boston 

PRIOR to the year 1907, infantile paralysis was rather 
an uncommon affection in this country. The severe 
New York epidemic of that year was followed in the 
two succeeding years by a great increase in the number of 
cases throughout the country, and since 1909 the disease 
has each summer claimed thousands of victims. As a result 
of this condition, clinical opportunities have come so fast 
that therapeutic knowledge has not been able to keep pace 
with them. Scientific knowledge of the disease in these 
years has also made great strides. The nature of the affec- 
tion and its organism have been identified; its pathology 
has been cleared up experimentally in animals and by nec- 
ropsy in the human being; and knowledge of symptomat- 
ology and prognosis has been greatly enlarged. But in the 
matter of therapeutics, in early cases especially, although 
we have made progress, we have made no great strides for- 
ward, and although cases on the whole are treated much 
better than they were ten years ago, we have today a very 
crude knowledge of the real value of the therapeutic meas- 
ures at our disposal, and of their proper application and 
limitations. Electricity and massage are much used, but 
not always intelligently. The proper dosage is uncertain, 
and rests on an empiric basis. Muscle training is of un- 
doubted value. We all believe in the use of affected muscles 



■"Copyright, 1915, Am. Med. Ass'n, and reprinted by permission from The Journal of the 
American Medical Association, June 26, 1915, Vol. LXIV, pp. 2118-2123. 

201 



202 INFANTILE PARALYSIS IN VERMONT 

so far as possible, but we know little of the effect of mus- 
cular fatigue on the paralyzed or partly paralyzed members. 
Much more exact knowledge in the lines indicated must be 
acquired before the best functional results can be obtained 
from treatment. 

It has been generally assumed that the distribution and 
the extent of the ultimate paralysis are wholly determined 
by the location of the lesions in the cord, but certain clinical 
aspects of the Vermont cases suggest that possibly there is 
another factor in this determination — that of muscle func- 
tion. The records of these cases have therefore been ana- 
lyzed, as a result of which the ground is taken in this paper 
that although infantile paralysis is apparently a widely dis- 
tributed and indiscriminate lesion of the cells of the an- 
terior cornu of the spinal cord, yet it would appear that the 
susceptibility of some motor centers was greater than that 
of others, influencing perhaps localization, and secondly, 
that the amount of residual paralysis was not wholly de- 
termined by the cord localization, but also influenced to 
some extent by the function of the affected muscles. 

The following preliminary report of the observation of a 
group of cases is offered in the hope that it may throw some 
light on certain phenomena of the affection, and certain 
deductions as to treatment are added, made from the obser- 
vation of these cases and of others. Certain investigations 
now being made at the Children's Hospital by the physio- 
logic department of Harvard University will, it is hoped, 
throw light on the value of some of our therapeutic meas- 
ures. 

In the fall of 1914, I was asked by the State Board of 
Health of Vermont if I would undertake on their behalf the 
treatment of the cases of infantile paralysis occurring there 
in the summer of 1914, of which there had been 306. A pri- 
vate citizen had given to the State Board of Health a certain 
sum of money to be expended on an investigation into the 



THE TREATMENT OF INFANTILE PARALYSIS 203 

epidemiology of the epidemic and on the treatment of the 
affected persons. Dr. Simon Flexner of the Rockefeller In- 
stitute consented to take charge of the epidemiology end of 
the inquiry, and I embarked on the enterprise of the treat- 
ment of these cases in December, 1914. 

The conclusions as to the epidemiology, occurrence, con- 
tagiousness, etc., I have left entirely to the other side of the 
investigation, and have confined myself strictly to the clini- 
cal aspect of the cases as observed. 

The problem of the treatment of so large a group of cases 
was of itself a new and difficult one. The physicians of these 
cases were notified by the State Board of Health of certain 
centers where clinics would be held, and I made five trips to 
Vermont, spending two days at a time there, for the pur- 
pose of prescribing treatment. Cases were grouped in Bur- 
lington, Barton, Montpelier, St. Albans and Rutland, the 
local hospital in each instance being utilized for the purpose, 
and to each of these places I went with my senior assistant, 
Miss W. G. Wright, and investigated and prescribed for the 
cases by groups. Every possible facility was afforded to 
me for this investigation, and the work everywhere was 
made easy and agreeable by the interest and cooperation of 
the physicians and by the very efficient assistance of the 
State Board of Health. 

The only possible solution of the matter seemed to be in 
enlisting the family physician and the family to cooperate 
in the treatment, because to have covered the state by a pro- 
fessional masseuse would have been practically impossible, 
and it seemed well under the circumstances to make the 
parents share as much in the responsibility for the treat- 
ment of the cases as might be possible. The principle was 
pursued where possible of seeing the patient with the doc- 
tor who was in charge, and after looking the patient over, 
apparatus was prescribed and provided when necessary, 
and in all cases that were likely to be benefited by it, in- 



204 INFANTILE PARALYSIS IN VERMONT 

structions were given as to muscle training and general 
routine. A chart was made of each case showing the af- 
fected muscles, and this chart was filed with the record of 
the patient dealing with certain etiologic factors, and de- 
posited with the secretary of the State Board of Health. 

It is the purpose of the state board to have these cases 
seen again in a few months, when it will be possible, by 
making new charts and comparing them with the original 
ones, to see how much progress has been made, and at the 
same time readjust apparatus and prescribe operations. 

The whole enterprise is interesting as a piece of construc- 
tive medicine, and the results of the treatment will of course 
be the most interesting part of the investigation, although 
certain facts already observed seem worthy of analysis. 

The epidemic of the summer of 1914 in Vermont was con- 
fined almost wholly to the northern half of the state, and 
there were reported to the State Board of Health 306 cases. 
Vermont is a state with 355,956 inhabitants, and the oc- 
currence of 306 cases represents a very high incidence of 
the disease. If one compares it with the New York epidemic 
of 1907, estimated in the report of the Collective Investiga- 
tion Committee at 2,000 cases, one finds that in Vermont 
there were per capita nearly twice as many cases as there 
were in the New York epidemic. It is of interest in this 
connection to note that the first large epidemic in this 
country was reported in the southern part of Vermont by 
Dr. Caverly* in 1894, when he reported 132 cases. From 
that time on there has been no serious epidemic in the state. 
In 1910 the disease began to come more in evidence, and in 
that year there were 69 cases. There were 27 cases in 1911, 
only 13 cases in 1912, and 47 cases in 1913. From these 
yearly fluctuations the jump to more than 300 cases in 1914 
is made.f 



*Caverly, C. S. : Notes of an Epidemic of Acute Anterior Poliomyelitis, The Journal 
A. M. A., Jan. 4, 1896, p. 1. 

tCaverly, C. S. : Bull. Vermont State Board of Health, June 1, 1914. 



THE TREATMENT OF INFANTILE PARALYSIS 205 

There applied for treatment at the clinics 235 cases, but 
a certain number of cases of other years were brought for 
advice, and a certain number of cases of other paralyses 
were brought, cutting down the number of the 1914 cases 
to 149, and it is from these 1914 cases that the conclusions 
presented are drawn. The youngest patient observed was a 
nursing baby aged 6 weeks at the time of the onset, and 
the oldest patient was 41 years old. One striking feature 
in the epidemic was that the incidence among older persons 
was unusually high. Between 10 and 20 there were thirty- 
eight cases, between 20 and 30 six cases, and between 30 
and 40 two cases. 

The severity of the infection is notable in this epidemic, 
inasmuch as the percentage of deaths was in the neighbor- 
hood of 17, which is high. For example, in Massachusetts, 
in 1,599 cases in the years 1907-1910 inclusive, the death 
rate was 7.9 per cent. Of course the apparent death rate 
depends on the thoroughness with which cases are reported, 
but in Vermont there is no reason to believe that cases were 
overlooked to any large extent, and it is probable that 
nearly all cases of frank paralysis have been reported, so 
thorough was the investigation of the state board. 

The difficulties attending the diagnosis of the affection 
were illustrated by some cases that were seen. A boy with 
a fractured elbow, while the arm was in the splint, was 
seized with an attack of fever, and had increased pain in 
the elbow. When the splint was removed, the arm was 
found entirely paralyzed from the shoulder down, and on 
examination was found to be a typical case of infantile 
paralysis. A boy with a congenital deformity of the foot, 
a talipes equinus, came to the clinic with a history of hav- 
ing always been lame, but after a feverish attack being 
much lamer. Analysis of the case showed a mixture of con- 
genital deformity and recent infantile paralysis. In one 
family two children of about the same age were brought, 



206 INFANTILE PARALYSIS IN VERMONT 

one with a typical cerebral hemiplegia of three years' dura- 
tion, the other one with a typical infantile paralysis of an 
arm and a leg. The family had classed them both as the 
same condition. Incidentally, two contemporaneous cases 
seen at the Children's Hospital may be mentioned, one of a 
child with a congenital dislocation of the hip in one leg and 
infantile paralysis in the other, and another child with an 
obstetric paralysis of the arm on the right side existing 
from birth, and a subsequent infantile paralysis of the leg 
on the same side. In most cases, however, the diagnosis was 
easy at the time when the patients were seen, and as a rule 
had been promptly made by the attending physician. 

An attempt was made to see whether any relation existed 
constantly between the severity of the attack and the degree 
of the paralysis, because in a paper published some years* 
ago, the statement was made that, in general, the severity 
of the attack corresponded to the intensity of the paralysis. 
The difficulty of finding out from the parents the facts as to 
the severity of the attack made information of this sort of 
no great value, because the majority of parents were in- 
clined to regard the attack as serious in any event. 

All patients were stripped, and the muscles were individ- 
ually tested as to function. Cases in babies, which could not 
be examined in this way, are not included in the report. The 
muscles were classed as wholly paralyzed, partly paralyzed, 
and normal. By wholly paralyzed is meant that no response 
could be elicited from a voluntary attempt to contract the 
muscle either in a contraction of muscular fibers or tighten- 
ing of the tendon. For this determination the muscle was 
given the most favorable condition of leverage ; for instance, 
to straighten the knee when the patient sits with the leg 
hanging requires a strong quadriceps, because the weight 
of the leg must be raised from the vertical to the horizontal 
position. If, however, the patient is laid on the affected side 

*Lovett, Robert W., and Lucas, W. P. : Infantile Paralysis, The Journal A. M. A., Nov. 
14, 1908, p. 1677. 



THE TREATMENT OF INFANTILE PARALYSIS 207 

on a smooth table and the knee flexed, much less muscular 
power is required to extend it, and very low grades of re- 
maining power can thus be detected v On this basis, if no 
power in any position could be detected in response to 
voluntary impulse, the muscle was classed as wholly para- 
lyzed. If any degree of contractile power in the muscle or 
tendon could be detected, or if the muscle had fair but not 
normal power, it was classed as partially paralyzed. Other- 
wise a muscle was classed as normal. 

The condition of each muscle was then marked on charts, 
which I originally obtained from Dr. E. A. Sharpe of Buf- 
falo, and these charts form the basis of the following analy- 
sis. It is not possible to determine with much accuracy the 
paralysis of the smaller muscles of the shoulder, hip, hand 
or foot, but with regard to the main muscles of the trunk 
and limbs, the determination could be made with a fair de- 
gree of certainty. The cases under analysis were seen in the 
winter of 1914-1915, and were of from two to six months' 
duration when examined. The majority of cases were of 
three or four months' duration. 

NATURE OF THE PARALYSIS 

It became evident that partial paralysis was much more 
common than total. Of 1,452 muscles affected, 416 were 
totally paralyzed and 1,036 partly, that is, the relation of 
partial to total paralysis was as 2.5 to 1. The ratio of par- 
tial to total paralysis varied in individual muscles, a mat- 
ter to be discussed later. 

A curious phenomenon was several times observed, where 
part of a muscle was paralyzed and the other part not. This 
was observed in the deltoid muscle, where the anterior or 
posterior half might work independently of the other, and 
once in the pectoralis major, where the sternal and clavicu- 
lar parts were separated by function. 

The predominance of partial over total paralysis is of 



208 



INFANTILE PARALYSIS IN VERMONT 



importance. The reason for it would seem to lie in the group- 
ing and relation of the nerve cells in the anterior cornua of 
the cord. These cells lie in longitudinal bundles, which are 
naturally largest in the cervical and lumbar enlargements. 



Forward horn 




\: 



(Wrumfy Se^. I 
Musc\e >Sp\t\oA 

>Spm<v\ 

Fig 1. — Radicular and peripheral muscular innervation. Muscle A sup- 
plied by segments 1 and 2 ; muscle B supplied by segments 1, 2 and 3 
(Bing). 

I quote from Bing:* 

Each contains fibers from several anterior roots, and, 
conversely, each anterior root distributes its fibers among 
several peripheral nerve trunks. . . . Anterior nerve root 
lesions, on the other hand, unless very extensive, merely 
weaken and do not completely paralyze the muscle, owing to 
the fact that as a rule the muscle is innervated from several 
roots. 

Moreover, we must remember that the poison of infantile 
paralysis apparently reaches the cord by means of the cir- 
culation, and that the main blood supply is from the anterior 
spinal artery, horizontal branches from which enter the 
cord at each side at different levels, about 200 in number. 
The planes of destruction, therefore, are likely to be trans- 
verse, while the lines of nerve center association are longi- 
tudinal, so that in the case of a muscle which derives its 
innervation from a group of nerve cells occupying several 



*Bing, Robert: Compendium of Regional Diagnosis in Affections of the Brain and 
Spinal Cord, New York, Rebman Company, 1909. 



THE TREATMENT OF INFANTILE PARALYSIS 209 

segments, a transverse lesion may well leave certain cen- 
ters intact, and some power may remain in the muscle. 
The iliopsoas muscle, for example, is innervated from the 
twelfth dorsal and first five lumbar segments, the quadri- 
ceps from the second, third and fourth lumbar, etc. 

This matter of partial paralysis is most important in the 
matter of treatment, as we shall see when we come to dis- 




Fig. 2. — Distribution of blood vessels and nerve cells in the transverse 
section of the cord. A, anterior spinal; A', posterior spinal; B, area of 
distribution of sulco- commissural artery ; C, tract cells ; D, root cells. 
1, postero-lateral ; 2, antero- lateral ; 3, antero-mesial ; 4, central; 5, 
postero-mesial (Bing). 



cuss the therapeutic measure of muscle training, because 
in such muscles there remains some initiative, and with it 
the power of developing more muscular volume and new 
associations by repeated passages of impulses from brain 
to muscle. 



210 



INFANTILE PARALYSIS IN VERMONT 



AFFECTION OF INDIVIDUAL MUSCLES 

A tabulation was next made as to the affection of individ- 
ual muscles, which shows that they were affected either 
partially or totally in the degrees indicated in Table 1. This 
table gives the number of total paralyses of each muscle, 
the number of partial and total paralyses, and the propor- 
tion of total to partial in each. 

The main facts are that the quadriceps, gluteals and gas- 
trocnemius lead in frequency, and that paralysis of leg 
muscles is much more frequent than of arm muscles. Ab- 
dominal paralysis existed in more than half of all the cases 
(seventy-nine), and affection of the muscles of the spine in 
more than a quarter (forty) . The latter points have a dis- 
tinct bearing on the occurrence of scoliosis, and indicate, I 



Table 1. — Degree of Affection of Individual Muscles 



Muscle Paralyz 

Adductors 68 

Gluteals 133 

Flexors of hip 81 

Quadriceps 152 

Hamstrings, outer 97 

Hamstrings, inner 95 

Gastrocnemius 128 

Tibialis anticus 119 

Peroneals 96 

Deltoid 57 

Trapezius 49 

Infraspinatus 17 

Pectoralis 29 

Biceps 31 

Triceps 28 

Abdominal 79 

Latissimus dorsi 49 

Spinal 40 

Flexor carpi ulnaris 16 

Flexor carpi radialis 16 

Extensor carpi ulnaris ... 19 

Extensor carpi radialis ... 18 

Opponens pollicis 12 

Extensor pollicis 23 







Proportion 


Number 


r Number 


of Partial 


Partial 


Complete 


to Total 


52 


16 


3.2:1 


106 


27 


3.9:1 


63 


18 


3.5:1 


119 


33 


3.6:1 


66 


31} 


2.7:1 


73 


22 


2.7:1 


88 


40 


2.2:1 


53 


66 


0.8:1 


40 


56 


0.7:1 


45 


12 


3.7:1 


42 


7 


6.0:1 


8 


9 


0.9:1 


22 


7 


3.1:1 


24 


7 


3.4:1 


22 


6 


3.6:1 


64 


15 


4.3:1 


40 


9 


3.4:1 


36 


4 


9.0:1 


12 


4 


3.0:1 


11 


5 


2.2:1 


14 


5 


2.8:1 


13 


5 


2.6:1 


9 


3 


3.0:1 


14 


9 


1.5:1 



1,452 1,036 



416 



THE TREATMENT OF INFANTILE PARALYSIS 211 

believe, that such affections are more common than had 
been supposed. The cases of abdominal paralysis were 
always symmetrical with two exceptions, one right and one 
left. This paralysis may occur as the only paralysis in the 
entire muscular system. When associated with paralysis of 
other parts, the association is always with leg muscles. 

The tibialis anticus and gastrocnemius are the only leg 
muscles which have been found to be affected by themselves 
without paralysis occurring elsewhere in the body. Of the 
former muscle, there were five cases of paralysis, of the lat- 
ter three. Deltoid paralysis may occur alone in the arm. 

The investigation of paralyses of the arm showed (1) 
that the paralysis was most frequent at the shoulder and 
diminished in frequency from the shoulder to the hand : (2) 
that the paralysis was severest (that is, that the percentage 
of total cases was largest) in the shoulder and diminished 
as one went toward the hand, and (3) that paralysis of the 
muscles of the left arm was very much more frequent than 
of the right arm. 

These three factors will be considered and tabulated, and 
then the leg will be considered in the same respects, after 
which the possible meaning of these phenomena will be dis- 
cussed. 



Table 2. — Figures Showing that Paralysis of the Arm Muscles 
Is Most Frequent in the Shoulder and Diminishes 

TOWARD THE HAND 

Total 
Muscle Paralysis 

Deltoid 57 

Trapezius 39 

Pectoralis 29 

Infraspinatus 17 

Shoulder group 142 -r- 4 = 35.5 

Biceps 31 

Triceps 27 

Upper arm group 58 -r- 2 = 29.0 



212 INFANTILE PARALYSIS IN VERMONT 

Total 
Paralysis 

Flexor carpi ulnaris 16 

Flexor carpi radialis 17 

Extensor carpi ulnaris 19 

Extensor carpi radialis 18 

Forearm group 70 -f- 4 = 17.5 

Opponens pollicis 23 

Extensor pollicis 12 

Hand group 35 -^ 2 = 17.5 



The figures 35.5, 29.0, 17.5 and 17.5 in Table 2 represent 
the mean paralysis per muscle in each group. The separa- 
tion at the point where the weight bearing of the arm di- 
minishes is very marked. The ratio between the groups 
above and below the elbow is 1.8:1. 

In Table 3, the last column gives the mean total paralysis 
per muscle in the region specified. The general ratio in the 
arm muscles of partial to total paralysis is 2.6:1, or about 
the same as in all the muscles considered together. 

Other facts about paralysis of arm muscles are as fol- 
lows : In cases in which the muscles of the upper extremity 
are involved without paralysis occurring at other parts of 
the body, it is more severe in this region than when the 
muscles of the legs are also involved ; that is, arm paralysis 
which is strictly regional is more severe than arm paralysis 



Table 3. — Figures Showing that Paralysis of the Arm Muscles 
Is Severest at the Shoulder and Diminishes 

TOWARD THE HAND 

Total 
Muscle Paralysis 

Deltoid 12 

Infraspinatus 9 

Pectoralis 7 

Trapezius 7 

Group 35 -r- 4 = 8.75 



THE TREATMENT OF INFANTILE PARALYSIS 213 

Total 
Paralysis 

Biceps 7 

Triceps 6 

Group 13 -^ 2 = 6.50 

Flexor carpi ulnaris 4 

Flexor carpi radialis 5 

Extensor carpi ulnaris 5 

Extensor carpi radialis 5 

Group 19 ~ 4 = 4.75 

Extensor pollicis 3 

Opponens pollicis 9 

Group 12 -^ 2 = 6.00 



Table 4. — Figures Showing that Paralysis of the Muscles op 

the Shoulders, Arm and Forearm Is More Frequent on 

the Left Side Than on the Right 

Muscle Right Left 

Deltoid 24 33 

Trapezius 18 21 

Infraspinatus 6 11 

Pectoralis 11 18 

Biceps 11 20 

Triceps 12 15 

Flexor carpi ulnaris 7 9 

Flexor carpi radialis 7 9 

Extensor carpi ulnaris .... 7 12 

Extensor carpi radialis .... 6 12 

Extensor pollicis 5 7 

Opponens pollicis 10 13 

Total 124 180 

Ratio 2 to 3 (very nearly) 

which exists in combination with more general paralysis. 
This statement rests on the analysis of fifty-eight cases. 

The relative frequency of paralysis of the thumb muscles 
(the opponens and extensors) was noticeable, and was 
found in thirty-five cases (Table 4). It probably existed in 
more cases among those first examined and was overlooked, 
because at the beginning of the inquiry it was not realized 
how commonly this existed in cases in which there was lit- 
tle or no other paralysis of the lower arm. 



214 INFANTILE PARALYSIS IN VERMONT 

With regard to paralysis of the muscles of the lower limb, 
the following facts were observed, which are of importance 
as contrasted with the similar observations in the arm : 

1. The paralysis was on the whole more frequent at the 
hip, and diminished in frequency toward the foot; that is, 
the individual muscles in the upper segment were more 
often affected than in the lower (Table 5). 

Table 5. — Figures Showing Greater Frequency of Paralysis in 

Upper Segment than in Lower 

Muscles No. 

Quadriceps 152 

Gluteals 133 

Gastrocnemius 128 

Tibialis anticus 119 

Outer hamstrings 97 

Inner hamstrings 95 

Peroneals 96 

Flexors of hip 81 

Adductors 68 

2. The paralysis was on the whole lightest in the hip, 
next lightest in the thigh and severest in the lower leg ; that 
is, the proportion of total to partial paralysis increased as 
one went away from the hip toward the foot (Table 6). 

Table 6. — Proportion of Partial to Total Paralysis in the 
Muscles of the Lower Extremity 
Muscles Partial to Total 

Gluteal 4.0:1 

Quadriceps 3.6:1 

Flexors of hip 3.5 : 1 

Adductors of hip 3.2 : 1 

Hamstrings 2.7 :1 

Gastrocnemius 2.2 : 1 

Tibialis anticus 0.8 :1 

Peroneals 0.7 :1 

RIGHT AND LEFT LEG 
With regard to the relative frequency of paralysis in the 
right and left leg, the figures show in a total of 954 paraly- 
ses of leg muscles that there were 465 muscles paralyzed in 
left legs and 489 in the right, showing no especial differ- 
ence in the affection of the two sides. This is a marked con- 
trast to the predominance of left paralyses in the arm. 



THE TREATMENT OF INFANTILE PARALYSIS 215 

ANALYSIS OF PREDOMINANCE OF PARALYSIS IN LEFT ARM 
AND FREQUENCY OF DISTRIBUTION IN ARM AND LEG 

Certain interesting problems are opened up by this study 
of arm and leg affections which demand analysis. The facts 
of paralysis occurrence are as follows : The muscles of the 
limbs nearest the trunk are more frequently affected than 
the distal ones; the left arm muscles are noticeably more 
frequently affected than the right. The leg muscles in the 
right and left leg are equally affected. 

The facts of use or function are that the right arm is 
much more actively used than the left, not only more fre- 
quently, but also for more varied and complicated and finer 
movements; the legs are used equally. It would therefore 
seem that muscles used actively, continuously and in a com- 
plicated way were more likely to escape than those less used, 
or used for simpler, less continuous work. One would sup- 
pose that the blood supply would be more free around the 
spinal centers where the motor activity was greatest and 
most complicated, and perhaps less free where the motions 
were less frequent and complicated. This would account 
for the predominance of left arm paralysis and the equal 
paralysis of both legs. 

After these figures were worked out, it seemed that such 
a relation between right and left should appear more in 
older than in younger patients, because in the younger ones 
the differentiation between the right and left arms is, of 
course, less marked than in the older, younger children be- 
ing much more nearly ambidextrous. If such a relation 
between right and left arms rested on a functional basis, it 
would be expected that there would be a larger proportion 
of left arm paralyses in older than in younger patients. In 
twenty-four patients 5 years old and younger, there were 
twelve left arms and twelve right paralyzed, a ratio of 1 : 1. 
In twenty-seven patients over 5 years of age (from 6 to 38 



216 INFANTILE PARALYSIS IN VERMONT 

years) there were twenty cases of left arm paralysis and 
seven of right, a ratio of 3 : 1. 

I should wish to acknowledge here my great indebtedness 
to Prof. W. B. Cannon and Assistant Professor Martin of 
the Physiological Department of Harvard University for 
much assistance on the physiologic side of the problem. 

This also accords with the distribution of the paralysis in 
both arms and legs, which has been shown to be most fre- 
quent near the trunk. The demands on the hip and shoulder 
muscles are simple and less continuous than on the muscles 
of the lower leg and forearm or of the hand and foot. The 
latter are continuously active in small, fine, complicated 
movements, whereas the larger muscles nearest the trunk 
deal with the coarser and less frequent movements. The re- 
lation between the activity of the proximal and distal parts 
of a limb are not unlike those of the left and right arm in 
their relative use. It seems probable from these facts and 
this grouping that, on the whole, muscle centers given to 
finer, complicated, more frequent movements have a more 
active blood supply and are less likely to attack on their 
nerve centers from the virus of infantile paralysis than the 
centers of muscles functioning in heavier, less complicated 
and less frequent movements. 

ANALYSIS OF SEVERITY DISTRIBUTION IN ARM AND LEG 

In the next place, it has been shown that the muscles of 
the upper extremity are more severely affected nearest the 
trunk and less severely lower down, whereas in the leg this 
relation is reversed, and the largest proportion of severe 
paralyses is in the lower leg and foot. This is estimated on 
the proportion of total to partial paralysis in the individual 
muscles. 

This puzzling phenomenon is more nearly correlated to 
the weight coming on each muscle in the activities of the 
upright position than to any other factor. The great major- 



THE TREATMENT OF INFANTILE PARALYSIS 217 

ity of these patients were walking in some form or other, 
so that the weight-bearing position may fairly be taken into 
account. 

At the shoulder, the deltoid, triceps and biceps all help to 
hold the arm up against the shoulder joint, and the weight 
to be met not only in this suspensory function, but also in 
attempted movements, is greatest at the shoulder and less 
as one goes down the arm, because the weight of the whole 
arm is obviously more than the weight of the lower one or 
two segments. Upper arm muscles, consequently, have more 
weight to handle than lower arm and hand muscles. 

In the leg, on the other hand, the weight to be met in 
muscular function increases as we go from the hip to the 
feet, as of course there is greater superincumbent weight 
at the lower leg than at the hips, so that the lower leg mus- 
cles must raise more weight than hip muscles in walking, 
for instance. There is, of course, no proof that this varia- 
tion in severity of paralysis is caused by this greater or less 
weight to be met in muscular function. The explanation 
accords with the facts, however, better than any other seems 
to do. Severity distribution cannot be connected with size 
of muscles, or function of a peculiar sort. It cannot be ex- 
plained by local circulatory sluggishness affecting depend- 
ent parts. It is not associated with anterior or posterior 
muscles, nor is it easy to connect it with spinal localization. 
It seems purely a segmental limb distribution, and whether 
it is or is not the correct explanation, severity of paralysis 
is proportionate to the weight to be met by the muscles of 
the different levels, not because this factor influences in any 
way the original affection of the cells, but because it may 
retard the recovery of those muscles working against the 
greatest weight. 

This suggestion has a direct bearing on the matter of 
treatment, for if it is correct it may be interpreted into 



218 INFANTILE PARALYSIS IN VERMONT 

showing the ill effects on muscular recovery of overuse, a 
matter which will be discussed later. 

Infantile paralysis has been heretofore regarded as a 
haphazard affection of muscles, most frequent in the leg, 
and in the cord lesion it appears to have a purely accidental 
distribution most marked in the lumbar enlargement. It is 
possible, however, that there are other factors than the cord 
lesion which determine the ultimate condition of affected 
muscles. The analysis just made as to frequency and se- 
verity of paralysis shows that in cases some months after 
the attack there are apparently existing conditions not 
easily to be explained by the cord lesion alone, but suggest- 
ing that function, and especially the function of maintain- 
ing the upright position, may have something to do with 
determining the ultimate distribution. 

ASSOCIATED PARALYSIS IN THE LEG 

Further pursuit of the inquiry suggested by the analyses 
just given takes up the question of muscular grouping in the 
leg. If the paralysis were a purely segmental affair wholly 
determined by the cord lesions, there would be in the limbs 
a roughly segmental distribution, muscles at the front and 
back of the thigh and front and back of the leg being more 
often paralyzed in this combination than in any combina- 
tion suggesting associated function. In other words, oppo- 
nents would be more often paralyzed in combination than 
would synergistic or functionally associated muscles at dif- 
ferent levels. 

The leg rather than the arm was selected for this analysis 
because of the greater simplicity of function in the former. 
In the arm, rotation movements complicate the more purely 
forward and backward movements of the lower extremity. 

The inquiry then resolved itself into the investigation of 
whether associated or antagonistic muscles were most often 
paralyzed in combination in the legs. 



THE TREATMENT OF INFANTILE PARALYSIS 219 

The muscles in the leg most closely associated function- 
ally are the gluteals, the quadriceps and the gastrocnemius, 
for they are the muscles which maintain the upright posi- 
tion. The gastrocnemius holds the tibia upright on the foot, 
the quadriceps holds the knee straight, and the gluteals 
hold the trunk erect on the legs. The associations were as 
follows: If the quadriceps is paralyzed, either the gluteals 
or the gastrocnemius, or both, are almost always associated 
with it. In 109 cases there were only two exceptions. In 
three cases the quadriceps had no association in the leg. In 
the 109 cases of quadriceps paralysis, to contrast with the 
106 associations of gluteals or gastrocnemius, there were 
only fifty-eight associations of paralysis of one or both ham- 
strings. The quadriceps, therefore, is affected nearly twice 
as often with its associated muscles as with its antagonists. 

When the gastrocnemius is involved, the quadriceps or 
gluteals were involved in 108 out of 109 cases; but the an- 
tagonists of the gastrocnemius, the extensor longus digito- 
rum and the tibialis anticus, either one or both, were para- 
lyzed in combination with it in only sixty-six cases. 

EXPLANATIONS OF PREDOMINANCE OF ASSOCIATION 

PARALYSIS 

This predominance of association paralysis is susceptible 
of several possible explanations, of which the following may 
be mentioned: 

1. The muscles which maintain the erect position are all 
very large, and must have large centers composed of many 
motor cells. On account of their very extent, therefore, they 
are more likely to be affected than smaller muscles by a 
generally distributed destructive process in the cord. That 
this is not altogether acceptable is shown by reference to 
Table 1, in which it will be seen that the tibialis anticus and 
peroneals, which are small, are of high incidence, and the 
pectoralis major, a large muscle, is of low incidence. 



220 INFANTILE PARALYSIS IN VERMONT 

2. The second explanation is that associated muscles may- 
be so intimately grouped in the arrangement of their motor 
centers in the cord that they are more likely to be involved 
in the same lesion than opposed muscles would be. If, how- 
ever, one may trust to the present data on the segmental in- 
nervation of these muscles, this view is not borne out. The 
gluteals are credited to the fourth and fifth lumbar and first 
and second sacral segments, the quadriceps to the second, 
third and fourth lumbar, and the gastrocnemius to the 
fourth and fifth lumbar and first and second sacral. The 
hamstrings belong to the third, fourth and fifth lumbar and 
first sacral, and the tibialis anticus to the fourth and fifth 
lumbar. These data are taken from Bing, and do not sug- 
gest that the levels of the different motor centers favor the 
groupings of associated muscles together or antagonists to- 
gether, nor does the grouping of the bundles as seen in cross 
section particularly favor this view. 

As to the arrangements of the columns in the cord I 
quote again from Bing : 

In general it may be said that the centers . . . for the 
muscles of the proximal segments of the limbs are to be 
found in the ventromeseal, while the two lateral groups 
govern the remaining segments of the extremities. The cen- 
ters for the coarser movements of flexion and extension are 
in the neighborhood of the periphery, while those of the 
finer movements (e.g., of fingers and toes) lie nearer the 
central groups. 

The following statement, from Van Gehuchten and De 
Buck,* would seem also to be against the assumption that 
anatomic grouping of centers of associated muscles explains 
the associated paralyses spoken of : 

Extending this conclusion to all the cellular groupings of 
the anterior horn of the spinal cord, as well in the cervical 
as in the lumbar enlargement, they defend the idea that the 
different natural grouping of nerve cells which exist at the 

*Van Gehuchten and De Buck: Rev. neurol., 1898. 



THE TREATMENT OF INFANTILE PARALYSIS 221 

periphery of the anterior horn in the cervical and in the 
lumbosacral enlargement are en rapport, with neither the 
peripheral nerves nor isolated muscles, nor with groups of 
muscles fulfilling the same physiological function. They are 
uniquely and exclusively en rapport with the muscles of the 
different segments. Medullary motor localization, therefore, 
is neither nervous nor muscular, it is segmental. 

3. The third explanation for the predominance of resid- 
ual paralysis in associated rather than antagonistic groups 
may be in the functional relation of the muscles themselves. 
Three muscles, the gluteal, the quadriceps and the gastroc- 
nemius, work together to maintain the upright position, 
and if a whole leg is lightly affected, it may be that the as- 
sociation of these muscles in function may retard their re- 
covery by their intimate and necessary functional depend- 
ence on each other ; especially if one were seriously affected, 
it might retard the recovery of the muscles associated with 
it by throwing more work on them than they were able to 
perform in their affected condition, which condition would 
not obtain with regard to antagonists. 

At this stage of the inquiry, it is not possible fairly to 
choose either one of these three explanations as the one to 
be accepted to the exclusion of the others. Perhaps the truth 
lies in a combination of the assumption that nerve centers 
of associated muscles are contiguous and that associated 
function may also be a factor. 



CLINICAL APPLICATION 

Such are the facts elicited in this preliminary analysis. Of 
course they mean something, and I have tried to interpret 
them as fairly as possible and let them tell their own story 
without reading into them anything that does not belong 
there. I have proved nothing, and my tentative conclusions 
are merely suggestions. Nothing more is warranted. But I 
should like to make what I believe to be a fair application of 



222 INFANTILE PARALYSIS IN VERMONT 

these conclusions to certain clinical aspects of treatment, 
and to leave the reader judge as to their applicability. 

I regard one point as fairly well established by these fig- 
ures, namely that there is another factor beside the plain 
anatomic distribution of the lesion in the cord which deter- 
mines something of the extent and severity of the residual 
paralysis. 

It will be necessary to review in a few words what I be- 
lieve to be the present status of the treatment of infantile 
paralysis before proceeding to the possible explanation of 
these facts. The affection is an acute one, and treated in the 
early stage by rest, because paralysis is generally present in 
the limbs, making activity impossible, and because the pa- 
tients are generally sensitive, and movement and handling 
are painful. It seems rational not to attempt to stimulate 
by massage or electricity or handling the peripheral con- 
nections of such seriously disordered nerve centers, and the 
best accepted usage is to let such cases alone, only striving 
to prevent contractions until sensitiveness has disappeared, 
but to allow the process of repair to go on undisturbed. The 
statement that electricity will kill the organism in the early 
stage is of course wholly unreasonable and unproved. It is 
the custom to prescribe hexamethylenamin at this stage, 
and many of us are of the opinion that clinically it is of use ; 
but in the Vermont series there was an interesting and sug- 
gestive case, in which a child had been taking 5 grains of 
hexamethylenamin for three or four days before coming 
down with a typical attack of infantile paralysis. 

With regard to holding off massage, etc., until after sen- 
sitiveness has disappeared, it rests on theoretical considera- 
tions and on empiric grounds. I had been convinced that it 
was correct, but thinking that perhaps I had fallen too 
much into a rut, after consultation last winter with a col- 
league skilled in neurology I attempted to institute earlier 
than usual the therapeutic measures in a case still tender, 



THE TREATMENT OF INFANTILE PARALYSIS 223 

in which the sensitiveness seemed of unreasonably long 
duration. 

A boy of 5!/2 years, paralyzed in Vermont in August, 
1914, was under my care at the Children's Hospital. At the 
end of nine weeks he was still decidedly sensitive in the 
paralyzed limbs, and on October 22 I decided to try the gen- 
tlest massage of five minutes a day to each leg. The massage 
was given by a highly skilled masseuse of great experience 
under my personal direction. In one week the boy was so 
sensitive that a cradle had to be put on the bed to protect 
him from the pressure of the bedclothes, and massage was 
omitted and both legs were put up in plaster of Paris. In 
one week more the plasters were removed, and it was found 
that the sensitiveness had wholly disappeared, nor did it 
ever return. One case, of course, proves nothing; but it is, 
I believe, indicative of a general principle. 

The tenderness may last from two to three months after 
the attack, and a perfectly inactive treatment is hard to 
pursue when the family has heard of the wonders of elec- 
tricity and massage, and is anxious not to lose time. But so 
long as the tenderness lasts, the best practice is to let the 
patient alone so far as active treatment goes. Frequent 
changes of position are desirable, and there is no objection 
to the sitting position for the convalescent, to outdoor air, 
or to immersion in a warm bath with whatever active move- 
ment under water may be accomplished without discomfort. 

There is no danger that the joints will stiffen, and in the 
first weeks the only troublesome complication to be feared, 
as has been said, is contraction of the Achilles tendon. 

With the disappearance of tenderness, the time for active 
treatment has begun, and the sooner the patient is put on 
his feet and resumes activity the better. It seems probable 
on general principles that in cases of any degree of se- 
verity, even if tenderness disappears earlier than four 
weeks, active treatment should not be begun before that 
time. The general condition of the patient must not be neg- 
lected, as many of the children at this time have not wholly 



224 INFANTILE PARALYSIS IN VERMONT 

recovered from the effects of infection, and are anemic, 
poorly, and easily fatigued. 

The therapeutic measures at our disposal in fairly early 
cases are massage, electricity and muscle training. 

Massage may be expected to improve the local and general 
circulation, to facilitate the flow of lymph, and to retard 
muscular deterioration. It cannot, however, be expected to 
facilitate the transmission of a motor impulse from the 
brain to the muscle. 

Electricity is less highly regarded in the treatment than 
was formerly the case. The unintelligent use of electricity 
month after month to the exclusion of other measures has 
been one of the handicaps which has stood in the way of the 
best progress in many cases. It is quite possible that it may 
improve the muscular condition. Statements of its value 
rest as a rule on bare personal assertion or on the unusually 
rapid improvement of individual cases; but cases vary 
greatly in their rate of improvement, and the only way to 
judge of the value of electricity is to use it on one side of 
the body in bilateral cases and use the other side as a con- 
trol. In the winter of 1913-1914, some cases in private 
practice were given daily treatments of galvanic electricity 
on one side and none on the other, while daily muscle train- 
ing was being given by my assistant, who was not told 
which side was receiving the electrical treatment. At the 
end of some months she was asked if either side had shown 
more rapid improvement than the other, and no difference 
had been noted. This simply confirmed my general experi- 
ence of many years of less careful observation. 

Muscle training, on the other hand, rests on a sound 
physiologic basis, works out empirically better than any 
other of the measures, and the large proportion of partial 
paralysis in the cases observed shows its reasonableness. It 
consists in an attempt to induce a voluntary impulse to pass 
from the brain, down the motor tracts of the upper neuron, 



THE TREATMENT OF INFANTILE PARALYSIS 225 

through the appropriate centers to the selected muscle. By 
the disease, certain spinal motor centers were destroyed, 
and can therefore no longer act to distribute motor impulses 
to their muscles. But such spinal centers and their connec- 
tions are complicated affairs, and every muscle is connected 
with several centers, every center sends impulses to more 
than one muscle, and, moreover, the connections between 
the spinal centers are many. Unless, therefore, the destruc- 
tion in the cord has been a very extensive one, it is likely 
that some of the motor centers in any one region will have 
escaped destruction, and that it may be possible to establish 
new connections around the destroyed centers. If a railway 
wreck occurs in the main line and the track is blocked, it 
is often possible to send trains by means of a branch line 
around the obstruction, so that service between the termi- 
nals is maintained. In the same way, after a wreck of cer- 
tain nerve centers, it may be possible by a modified route to 
send a motor impulse from brain to muscle. On this prin- 
ciple of establishing new connections and opening new paths 
rests most of the claim of muscle training. 

Muscle training in its most obvious form consists in aid- 
ing the patient to perform a certain movement with the 
hope of stimulating an impulse from the brain to the mus- 
cles. If, for instance, the dorsal flexors of the foot do not 
act, through being stretched, weakened, partly paralyzed, or 
wholly paralyzed, in the exercise the foot is dorsally flexed 
with the hand and the patient directed to assist. If there is 
any muscular response, less and less aid is given to the mus- 
cle by the hand, and it may be that in this way it can be 
trained to perform its function.* 

Another and equally useful form of muscle training con- 
sists in getting the patient on his feet at the earliest possi- 
ble moment in order to call forth the instinctive muscular 
actions induced by the efforts and balance. Even before it 

*Wright: Muscle Training in the Treatment of Infantile Paralysis, Boston Med. and 
Surg. Jour., Oct. 24, 1912. 



226 INFANTILE PARALYSIS IN VERMONT 

is possible to make much progress in this way, sitting is 
useful for the spinal and trunk muscles. 

THE USE OF APPARATUS AND BRACES 

Many patients at the beginning are unable to stand with- 
out apparatus, because, for example, the knees flex on ac- 
count of weakness or paralysis of the quadriceps muscle. 
In these cases a caliper splint should be applied to hold the 
knees straight. If the feet roll in or out, varus or valgus 
braces should be applied. If the spine or abdomen is in- 
volved, a corset or jacket should be worn. Crutches are at 
first necessary in cases of paralysis of both legs. In other 
words, if the standing position induces malposition, such 
malposition must be corrected, because nothing but harm 
can come of it. 

The fear that the early use of apparatus will promote 
muscular atrophy is wholly unreasonable, because disuse is 
bad. Braces should mean the upright position, and the up- 
right position means more muscular activity. The best way 
to avoid wearing a brace permanently is to put it on early 
and keep it on as long as necessary. For a growing child 
to walk about with a malposition is to bid for a permanent 
deformity. 

DEFORMITY 

If fixed deformity exists, it must be removed before treat- 
ment of any sort can be satisfactory. By fixed deformity is 
meant a condition in which the functions of a joint are 
limited, in which its arc is restricted. 

An analysis of the deformity of these cases seen from two 
to six months after the onset was as follows : 

Equinus was the most frequent deformity, and was pres- 
ent in sixteen cases. It seems to me very creditable to the 
medical profession of Vermont that the proportion of equi- 
nus should have been so small. 



THE TREATMENT OF INFANTILE PARALYSIS 227 

There were nine cases of flexion of the knees and seven 
of flexion of the hips, sixteen cases of scoliosis, and four 
cases of hyperextension of the knees, one case of torticollis, 
and two cases of calcaneus deformity due to gastrocnemius 
paralysis. 

The grade of contraction deformity in these cases was a 
surprise to me, as I had not realized that in so short a time 
such serious deformities could arise. There were cases of 
scoliosis of only a few months' duration which I should have 
supposed it would take at least one or two years to acquire. 
The flexion deformity of the hips and knees in one or two in- 
stances was striking, in one case one knee being flexed to 90 
degrees and the other to 45, with both hips in flexion con- 
traction. Other cases of severe contraction of the knee and 
hip, only to be remedied by stretching or tenotomy, were 
seen among the 1914 cases. Contraction of the shoulder in 
a forward position, not allowing the outward, upward and 
backward movement, was found in three cases of deltoid 
paralysis. 

The operative attack on deformity, apart from the per- 
formance of minor tenotomies and operative measures in 
general, are by common consent to be postponed until three 
years from the acute attack. Operative treatment will not 
be considered in this paper because it is by far the best 
formulated part of the treatment, and because lack of time 
forbids. 

OVERFATIGUE AND OVERUSE 

We come now to the final, and what I believe to be the 
most important part of the paper, namely, the possible ef- 
fect of overfatigue and the overuse of massage on returning 
muscular function, a phase of the treatment question almost 
wholly neglected. 

If we take the case of a partly paralyzed muscle with 
some remaining power, we are anxious to bring about in 



228 INFANTILE PARALYSIS IN VERMONT 

that muscle the greatest possible return of functional power ; 
that is plainly our object of treatment. Now the rational 
exercise of a normal muscle results in increase of size and 
power of that muscle, and presumably the result would be 
the same in a muscle weakened by infantile paralysis which 
was rationally and physiologically exercised or massaged. 
We are, however, dealing with muscles in many instances 
very weak and incapable of doing much work, and it must 
be an easy thing to overexercise them. 

As to the question of this overuse, the following facts are 
suggestive: The majority of the early cases seen in Ver- 
mont showed partial rather than total paralysis; the gas- 
trocnemius muscle in cases of early paralysis was quite dif- 
ferent from the stretched, lengthened and powerless gas- 
trocnemius muscle of late cases. Muscles partly paralyzed 
in which power is returning may be rendered functionless 
by slight grades of overuse. These considerations all have 
a bearing, and in connection with observations to be men- 
tioned, indicate the possibility that in many cases of infan- 
tile paralysis we are encouraging in partly paralyzed mus- 
cles a function wholly beyond their ability, and are thus 
delaying their return of power and possibly converting par- 
tial into total paralysis. The observations follow : 

It has been repeatedly observed in my private practice 
that power might begin to return in a very faint degree to 
a muscle while under muscle training, and that with care 
this power would steadily increase, but if that muscle were 
exercised even very gently every day, that power would 
diminish or disappear, so that we exercise such muscles 
only once in three days at the outset, increasing the work 
most carefully. 

A young man under my care, severely paralyzed in both 
legs, six months after the attack showed some return of 
power in the peroneals. This developed and was exercised 
in the usual way, but he was so delighted with the new 



THE TREATMENT OF INFANTILE PARALYSIS 229 

function that one year after the attack he tried it at inter- 
vals all of one day on the principle that if a little exercise 
were good a large amount would be better, and the power 
promptly disappeared, never to return in full amount after 
some five months. 

A young man with a paralysis of the left arm acquired 
in Vermont in September, 1914, was brought from New 
York to see me in December, 1914. He was having mas- 
sage and exercises daily from an apparently competent 
masseur, and was urged to use his arm as much as he could 
to stimulate returning function; but for a month he had 
not improved, and the parents therefore decided to send 
him to me for treatment. He could not, however, come to 
Boston for a month, and asked what treatment he should 
pursue in the meantime. A sling supporting the shoulder 
was put on, he was forbidden to use the arm except at 
meals, and massage was stopped. After a month of this rou- 
tine he showed at least 25 per cent of increase of power. 

I saw with Dr. F. B. Percy of Brookline, Oct. 19, 1914, a 
child of 10 with a total paralysis of the anterior tibial mus- 
cle and partial paralysis of the gastrocnemius. Ten days 
after the attack, sensitiveness had gone, but the child could 
only walk badly and unsteadily. She was kept quiet for a 
month more, when she was allowed to walk a few steps 
daily. She made a remarkable gain, and massage and mus- 
cle training were begun, Jan. 6, 1915, although the amount 
of walking was not increased to any extent, the child walk- 
ing only a very little. In four months the gastrocnemius 
and tibialis anticus had apparently nearly normal power 
when their resistance was tested by the hand, but the child 
still limped a little. Feb. 24, 1915, four months after the 
attack, the mother was asked to keep this child practically 
off of her feet for two weeks while the other conditions of 
treatment were the same. At the end of this time the limp 
had disappeared. 

Oct 5, 1914, I saw a child of 5 with nearly complete 
paralysis of one leg below the knee from an attack three 
months previous. The child walked badly, but was much 
helped by a brace to hold the foot at right angles to the leg. 
Muscle training was started, and the child improved satis- 
factorily, evidences of returning muscle power becoming 
plain. March 6, 1915, the mother made a statement that 
attracted my attention, namely, that the child walked bet- 
ter in the morning than at night. She was asked to keep 
the child off of his feet as much as possible for a month, 



230 INFANTILE PARALYSIS IN VERMONT 

restricting walking to the greatest possible degree. April 
6, 1915, examination showed during the month a very strik- 
ing increase in power in the muscles controlling the foot, 
and it was evident that the progress in the last month had 
been far greater than in any previous month, and the child 
walked as well at night as in the morning. 

These illustrative cases seem to me to show that much 
smaller degrees of overuse may be deleterious than is gen- 
erally supposed. Probably any of us would agree that gross 
and persistent overuse of partly paralyzed muscles would 
be undesirable; but it seems to me reasonable that in the 
early stage of returning power, we should be exceedingly 
careful in the use of muscles in walking and in the use of 
heavy and prolonged massage, much more careful than we 
are at present, if I may judge the practice of others by my 
own previous methods. 

I hesitate to reason from an unproved conclusion in this 
connection; but may I once more call attention to the fact 
that the proportion of total to partial paralysis is greatest 
in the muscles which have the greatest weight to oppose in 
the standing and walking position and least in those which 
have the least weight, in a series of cases observed some 
months after the acute attack. If overuse is the harmful 
factor that I believe it to be in retarding recovery, its effect 
would be noted in just those muscles which show the high- 
est proportion of total paralysis. 

CONCLUSION 
It would be useless to present a summary of a paper 
which is only a summary in itself. It is merely the prelimi- 
nary report of a series of observations bringing out certain 
facts apparently bearing on some of the phenomena of the 
disease. Certain of these facts may later prove of practical 
significance or they may not. One of the observations I be- 
lieve to bear on the question of treatment, but even of that 



THE TREATMENT OF INFANTILE PARALYSIS 231 

one cannot be sure until after the second series of observa- 
tions is made on these same cases. This may perhaps throw 
some light on the later condition of the muscles — light 
which may have some practical bearing. 
234 Marlborough Street. 



INFANTILE PARALYSIS IN VERMONT 

A Report of the Progress of Cases between 
January, 1915, and July, 1915.* 

Robert W. Lovett, M.D. 

AND 

Ernest G. Martin, Ph.D. 
of Harvard University 



IN December, 1914, the State Board of Health of Ver- 
mont, through the generosity of an interested citizen of 
the state, was enabled to undertake the treatment of the 
cases of infantile paralysis occurring in the summer of 
1914, and the matter of treatment was undertaken by one 
of the writers, the general aspects of the epidemic and the 
epidemiology being undertaken by the Rockefeller Insti- 
tute of New York. Five trips were made to Vermont for 
the purpose of seeing and prescribing for cases. Clinics 
were held at Barton, Burlington, Montpelier, St. Albans and 
Rutland, the cases being assembled in these places for the 
purpose of examinations. There applied for treatment at 
the clinics 235 cases, but there were a certain number of 
cases from other years, which cut down the number of the 
1914 cases applying for treatment to 149. 

In each of the cases an examination was made, and the 
muscles affected were marked on a chart as "Totally para- 
lyzed," "Partially paralyzed" or "Normal." The needs of the 
case were then formulated, braces were prescribed when it 
seemed necessary, certain minor operations were advised, 
and in cases where it seemed likely to be of use the parents 
were instructed in muscular exercises to be given to the 



*Read at the Annual Meeting of the Vermont State Medical Society, Oct. 14, 1915. 

232 



A REPORT OF THE PROGRESS OF CASES 233 

patients for the development of partly affected muscles. 
Certain cases were not available for this treatment, because 
they were either too severely affected- or too young, but in 
the majority of cases this treatment by muscular exercises 
was instituted, and the parents were urged to follow it up. 

Subsequently these 149 cases were analyzed as to various 
points of interest with relation to the relative frequency of 
muscles affected, and other points likely to be of practical 
importance, and these conclusions were published in the 
Journal of the American Medical Ass'n, June 26, 1915. 

In order to carry the work through, at the request of the 
Board of Health, a second series of clinics was held in Ver- 
mont by both of the writers in July, 1915, and cases were 
seen at the same places as in January. On this trip there 
was used a newly devised method of testing the muscular 
strength of affected muscular groups. It had proved so use- 
ful in a preliminary trial at the Children's Hospital, Bos- 
ton, in the spring and early summer of 1915 that it was 
deemed worth while to attempt in Vermont to secure more 
definite information than could be obtained by the usual 
methods of examination as to certain phenomena of the dis- 
ease which it was believed would be of value in regard to 
problems of treatment. Muscle charts were also made on 
the second trip, but in contrast with the closer method of 
examination devised they proved to be of much less value 
than the figures from the new method. 

One of the most important facts developed by the original 
examination of the Vermont cases was that in something 
more than a third of the 149 cases examined on the first trip 
partial paralysis was more common than total paralysis, a 
fact which apparently had not before been realized. Now 
the term "partial" paralysis indicates any condition from 
that of a muscle which seems perhaps a little less vigorous 
than normal to one which shows only a flicker of contrac- 
tion on attempted voluntary movement. Yet neither of these 
muscles are normal nor wholly paralyzed. 



234 INFANTILE PARALYSIS IN VERMONT 

With regard to the completely paralyzed muscles and the 
normal muscles there was no special difficulty in classifica- 
tion, but it became evident very early in the investigation 
that partially paralyzed muscles might gain very much in 
power without passing out of the class of partially para- 
lyzed muscles, so that a comparison of the charts of the first 
and second trips in many cases showed the same markings, 
whereas very great increase in functional activity in many 
of these cases had occurred. It was evident that any closer 
study of importance must be made by means of the muscle 
testing method rather than by the muscle charts, where the 
power of voluntary contraction was estimated by hand. The 
study of the progress of the cases by this method is now 
being carried on, and will be reported on later, and for the 
present it is possible to speak only of the gross phenomena 
manifested by the comparison of the records, examinations 
and charts of the two visits, reinforced by certain prelimi- 
nary conclusions drawn from the method of muscle testing. 

On the second trip, at the five clinics held, 145 cases were 
seen, examined and prescribed for. Seven of these cases 
proved to be for affections other than infantile paralysis, 
reducing the number for analysis to 138. Three of these 
cases had occurred in the summer of 1915, 96 in the summer 
of 1914, and the remainder were distributed between previ- 
ous years, reaching as far back as 1894. Of these 138 cases, 
62 were seen for the first time in July and 76 were seen at 
the time of the visit in the winter and in July also. 

The following table shows the number of cases seen at the 
different clinics: 

Total Cases Cases Seen Cases Seen Not In- 
Seen in July First Time 2nd Time fantile 

Montpelier 22 10 8 4 

Burlington 48 22 24 2 

St. Albans 30 9 20 1 

Barton 21 7 14 

Rutland 24 14 10 

Total , 145 62 76 7 



A REPORT OF THE PROGRESS OF CASES 235 

On the July trip it was found that there had been im- 
provement in every case which had previously been seen 
with four exceptions. One boy, slightly affected, was said 
by his parents to be no better, and three patients had not 
followed the treatment prescribed and had not improved. 
The improvement in general was partly spontaneous and 
partly due apparently to treatment. The treatment was 
muscle training carried out at home, with in most instances 
restriction of activity. It developed early in the first visit 
that fatigue was evidently an unfavorable factor, and that 
exercise and activity must in many instances be cut down. 

Before proceeding to any conclusions it may be well to 
speak of the cases seen at the various clinics somewhat in 
detail. 

Montpelier. — Of 22 cases seen, four were not infantile 
paralysis, 10 were seen for the first time and eight for the 
second time. Of the eight cases seen for the second time two 
walked with braces who had not walked before, one walked 
without a crutch, one had practically recovered at the first 
visit and had remained well, and four showed very striking 
muscular improvement, as shown by comparison of the 
charts, several deltoids, forearm, gluteals and quadriceps 
muscles having changed either from total to partial paraly- 
sis or from partial paralysis to recovery. 

Rutland. — Twenty-four cases were seen, 14 of them be- 
ing seen for the first time in July. Of the 10 cases seen on 
both visits five were cases affected in 1911, and may be 
mentioned separately. Of the 1911 cases one case had been 
operated upon and was greatly improved. In one there was 
no note of function, although the parents described the case 
as better. In one there was no treatment and no improve- 
ment, and in two great improvement. Of cases affected in 
1914, three showed great improvement, one was too young 
for an accurate record but was better, and one was better 
but there was no definite note of function. 



236 INFANTILE PARALYSIS IN VERMONT 

Barton. — Twenty-one cases were seen, seven for the first 
time and 14 for the second time. These comprised some of 
the severest cases in the state, and improvement had oc- 
curred in all. Practical recovery had occurred in two, one 
could walk who could not walk before, several walked much 
better, and from a study of the charts it was found that 
there were many instances of total recovery of muscles 
partly paralyzed in the winter. 

St. Albans. — There were seen 30 cases, nine new ones 
and 21 seen for a second time. One case of gastrocnemius 
paralysis had had no treatment and had grown worse from 
neglect. High heels had been prescribed, which had not been 
used, and no exercises had been done. The gastrocnemius 
had stretched and had lost power. This was the only case 
of gastrocnemius paralysis seen in the state which had not 
improved under the treatment prescribed, which consisted 
in elevation of the heels, restricted use and exercises. Three 
cases were babies too young for exercise, and one case was 
too unruly for examination. All had improved somewhat. 
Two who could not walk in January could walk with a brace 
in July, 13 were much improved, in one the diagnosis was 
uncertain and the case was probably not infantile paralysis, 
and in one the notes were unsatisfactory. 

Burlington. — Forty-eight cases were seen. Two cases were 
not infantile paralysis, 22 cases were seen for the first time 
and 24 for the second time. Of these 24 cases one had had 
no treatment and showed no improvement, one was too 
young for accurate data but had improved, one was unruly 
and could not be carefully examined. In the remaining 21, 
improvement from slight to very great was recorded. In 
individual muscles the following changes were noted be- 
tween January and July. 

Partial Paralysis Total to Partial 
to Recovery Paralysis 

Deltoid 6 1 

Pectoral 3 



A REPORT OF THE PROGRESS OF CASES 237 

Partial Paralysis Total to Partial 
to Recovery Paralysis 

Trapezius 3 1 

Triceps 1 

Arm muscles 2 

Forearm muscles 1 

Back muscles 5 

Abdominal muscles 5 1 

Quadriceps 1 2 

Hamstrings 2 

Gastrocnemius 4 

The two most striking cases in the Vermont series were 
to be found in the Burlington group. A man of 38, attacked 
in August, 1914, was helpless and brought to the January 
clinic on a stretcher, and was with one exception the se- 
verest case seen in Vermont. In July he was earning his 
living by selling farm machinery in his wagon, taking a boy 
to help him in and out. He walked with one crutch with 
assistance also on one side, he was able to fish, and had been 
on a successful fishing trip during the summer. A girl of 
18, affected in 1914, in January could barely walk alone. In 
July she walked with a slight limp. Eight important mus- 
cles had recovered under persistent exercise, and the im- 
provement began a few days after starting on exercises, 
previous to which the patient's progress had been station- 
ary. 

In view of the facts developed on the second trip, the 
State Board of Health determined to pursue the treatment 
more accurately, it having evidently demonstrated that it 
was of use, and Miss J. B. Merrill stayed in Vermont from 
July until the end of September for the purpose of giving 
the treatment in various parts of the state to patients who 
were likely to be benefited by it. Two subsequent trips to 
Vermont were made by Dr. Martin for the purpose of test- 
ing the muscles of the cases under treatment, and the im- 
provement recorded was so striking that the Board decided 
to have Miss Merrill make trips through the winter at in- 
tervals of two weeks to various parts of the state for the 



238 INFANTILE PARALYSIS IN VERMONT 

purpose of seeing that the treatment was carried out, seeing 
the parents at frequent intervals, changing the exercises 
when necessary, and encouraging the parents to a steady 
pursuance of the treatment. 

The advantage of having a quantitative test for muscular 
strength is that it eliminates personal opinion as to the 
progress of an individual case and formulates the matter in 
pounds and ounces, so that by a comparison of the records 
of the same cases at intervals it is possible to find out 
whether or not the child is gaining or losing. Although at 
present it is not possible to present the full data with re- 
gard to the results of these observations by the muscle test, 
it may be said that the cases analyzed so far show that the 
expectation of improvement in a given muscular group af- 
fected but not totally paralyzed by the disease under con- 
stant treatment of muscle training from an expert is greater 
than under supervised home exercises, and that this is more 
likely to help than home exercises prescribed but given 
without supervision. Untreated affected muscles in these 
patients improve least, but even these show an improve- 
ment ratio of 1.9 to one, which latter is to be counted partly 
as spontaneous improvement, but it must be remembered 
that other muscles in the same case were being treated. 

These cases were nearly all affected in 1914, and repre- 
sent cases at the end of the first year. That spontaneous 
improvement is so marked at the end of a year is apparent- 
ly a new point, and one of great importance to us in form- 
ing our prognosis. These facts may well give us courage to 
undertake a more vigorous treatment in old cases, knowing 
that at the end of a year spontaneous improvement is by no 
means at an end. Perhaps we may find that it extends much 
later than this when our observations have covered a longer 
time. The possibility of improvement in muscles totally 
paralyzed at the end of one year was shown by observation 
with the muscle test. 



A REPORT OF THE PROGRESS OF CASES 239 

These figures and these clinical conclusions would seem 
to indicate that the venture of the State Board of Health of 
Vermont in undertaking on a large scale the treatment of 
cases of infantile paralysis by modern methods had been 
successful. That the cases on the whole improved more 
than would have been expected from spontaneous improve- 
ment alone seemed evident. That very great improvement 
had resulted in certain cases was equally plain, and the fact 
that so few cases out of the large number treated had failed 
to improve is apparently encouraging. The cases on the 
whole were not what one would select as a class on which to 
demonstrate the efficacy of any treatment. In a measure 
the patients were the children of farmers living in the coun- 
try, and often unable to receive much care from the mothers 
of large families. The parents have nevertheless been suffi- 
ciently interested in the treatment as a whole to give it an 
intelligent trial, with results which apparently have been 
beneficial. 

The care of a large group of cases of infantile paralysis 
has apparently not been undertaken in this country before, 
and it presented many difficult problems, but the outcome 
seems to have justified the undertaking, and it is hoped that 
when the data of the muscle tests have been formulated 
some definite increase to our knowledge of infantile paraly- 
sis may have been obtained. 



CERTAIN ASPECTS OF INFANTILE 
PARALYSIS 

With a Description of a Method of Muscle 

Testing* 

Robert W. Lovett, M.D. 

and 

E. G. Martin, Ph.D. 

THIS paper contains the account of a combined physio- 
logic and orthopedic study of certain phenomena of 
infantile paralysis. The whole matter owes its incep- 
tion and present status to the State Board of Health of Ver- 
mont, which by the generosity of an anonymous donor was 
enabled to finance a scheme for the study and treatment of 
the disease quite unprecedented in its scope and thorough- 
ness. The entire work has been conducted under the direc- 
tion of the board, which has borne the whole expense of the 
studies in Boston and Vermont. 

The inquiry was started in the late autumn of 1914, the 
Rockefeller Institute through Dr. Simon Flexner taking 
charge of the epidemiologic end of the inquiry and opening 
a laboratory in Burlington, while to one of us (R. W. L.) 
was assigned the therapeutic side of the problem. Later, 
for reasons to be stated, the physiologic department of Har- 
vard University was asked to assist in the study, and a 
system of muscle measurement was devised by one of us 
(E. G. M.). 

This system of measurement was put in use in the early 
summer of 1915 in the orthopedic department of the Chil- 
dren's Hospital, and later used by us in a trip to Vermont 



*A Report to the State Board of Health of Vermont. Copyright, 1916, Am. Med. Assn. 
and reprinted by permission from the Journ. of the A. M. A., Mar. 4, 1916, Vol. LXVI, 
pp. 729-733. 

240 



CERTAIN ASPECTS OF INFANTILE PARALYSIS 241 

made in July, 1915, for the purposes of treatment. So much 
new light was thrown by its use on certain phenomena of 
the disease that two subsequent trips to Vermont were made 
by one of us (E. G. M.) in August and September to make 
observations on patients under treatment. 

The material available for study is as follows : At the first 
series of Vermont clinics in January and February, 1915, 
235 patients applied for treatment, and at the second series 
in July, 145. From these figures should be deducted seventy- 
six seen at both clinics, making 304 patients seen and pre- 
scribed for in Vermont. One hundred and one patients from 
the orthopedic clinic of the Children's Hospital, Boston, and 
from the private practice of one of us have been added to 
the Vermont material for purposes of study. The results of 
the analysis of cases on the first trip have been published,* 
and a short preliminary report on the method of muscle 
testing has been made.f 

In the present paper we first discuss the reasons for the 
use of a muscle test, second, describe the muscle test, and 
third, present conclusions obtained by the use of the muscle 
test in the cases mentioned. 

The general thesis of this paper is as follows : The obser- 
vations in about 300 cases in Vermont have shown that in 
all cases, old and recent, infantile paralysis has been found 
in most muscular groups not to be a paralysis in the sense 
of a complete loss of power, but a weakening of these mus- 
cles. Now weakened muscles can, as a rule, be made stronger 
by judicious exercise, just as can normal muscles. Our 
therapeutic problem, therefore, requires the closest possible 
study of such muscles and of the therapeutic means by 
which their individual power may be increased. It is a very 
important matter to the parents of a child with a gastroc- 
nemius muscle reduced to only 20 per cent of its normal 

*Lovett, R. W. : The Treatment of Infantile Paralysis : Preliminary Report, Based on 
a Study of the Vermont Epidemic of 1914, The Journal A. M. A., June 26, 1915, p. 2118. 

tMartin, E. G., and Lovett, R. W. : A Method of Testing Muscular Strength in Infantile 
Paralysis, The Journal A. M. A., Oct. 30, 1915, p. 1512. 



242 INFANTILE PARALYSIS IN VERMONT 

power whether this muscle ultimately returns to 40 per cent 
or 90 per cent of its normal strength. 



WHY A MUSCLE TEST WAS DESIRABLE 

The original study of the Vermont cases, in which the 
hand was used to estimate voluntary contractile power in 
the individual muscles, showed in 150 cases of a few months' 
duration that partial paralysis was more common than total 
in the proportion of 2.5 :1 (1,036 partial to 416 total paraly- 
ses). In the eighty-six cases of the 150 available in July for 
closer study by means of the muscle test, there were found 
by this method 111 totally paralyzed and 958 partially para- 
lyzed muscle groups, a proportion of about 9:1. It is evi- 
dent, therefore, that the bulk of any study will be in cases 
of "partial paralysis." 

At the outset of the Vermont work, muscles were classed 
as normal, partly paralyzed or totally paralyzed. The first 
and the last class were clear enough, but in the "partly 
paralyzed" division we had to group muscles which were 
just short of normal and muscles which showed only a 
flicker of movement on attempted contraction. Between 
these two widely separated conditions existed every degree 
of disability, yet one must put them all in one class. Exact 
study of the phenomena under these conditions was impos- 
sible. 

Again, in the matter of treatment some scale of measur- 
ing improvement or the reverse was urgently needed. "Im- 
pressions" that electricity of one kind or another, or rest or 
exercises were beneficial have filled literature; unsupported 
assertions, marvelous cures, fantastic treatments have too 
often been advanced on the slenderest of grounds. With the 
realization that partial paralysis was the usual form of af- 
fection, it became imperative to have some scale by which 
to work out what should be a precise and improved treat- 
ment. The muscle test offers a practical quantitative scale 



CERTAIN ASPECTS OF INFANTILE PARALYSIS 243 

by which the effects of modifications of treatment may be 
studied week by week and month by month. 

The muscle test devised consists of -estimating strength 
of the various muscular groups by means of spring balances 
and is considered in the next article (p. 252). 

CONCLUSIONS DRAWN FROM THE USE OF THE MUSCLE TEST 

The following observations rest on studies on 177 pa- 
tients, on whom 13,000 observations in 400 series were 
made, forty-four different muscular groups, twenty-two on 
each side of the body, being available for study. 

Distribution of Paralysis. The muscular affection is much 
more widespread than ordinarily supposed, thus corre- 
sponding closely to the pathology as observed of late years. 
It is rare to find one muscular group affected without mani- 
festations elsewhere ; for example, we often class a case as 
gastrocnemius paralysis, but rarely in our observations 
(two in 177) has this been found to exist alone, other mus- 
cles nearly always being weakened. When one leg is in- 
volved it is common to find some weakening of some of the 
muscles of the other leg. When both legs are affected, some 
arm muscles are often involved. This fact is well to bear in 
mind in formulating treatment. 

In thirty-two cases of the series, taken consecutively from 
the files for this analysis, the following data were observed : 

Ten cases by manual examination had been classed as 
having only one leg affected; by the muscle test nine of 
these showed weakness of muscular groups in the other leg. 
Of the other twenty-two cases, four had obvious paralysis 
of all four members. In the remaining eighteen cases of 
paralysis of more than one limb, no new paralysis was re- 
vealed by the muscle test in eight, while in ten, unsuspected 
involvement in another limb was found. 

Distribution of Total and Partial Paralysis. Table 1 
shows that there is a predilection on the part of total pa- 



244 INFANTILE PARALYSIS IN VERMONT 

ralysis for the lower leg. In the Boston series the cases 
were of longer duration, of a severer type, many requiring 
operation, but the ratio is not widely different in the two 
classes. This confirms the observations made in the 150 
cases seen on the first trip, where the peroneal and anterior 
tibial muscles showed of all muscles the largest incidence of 
total paralysis. 

Partial paralysis may be classed as severe (one third or 
less of normal power) or moderate (one third or more of 
normal power). Two classes of cases are available for this 
analysis, one the Vermont group, mostly affected in 1914, 
and the other the Boston group, mostly affected before 1912, 
being largely hospital cases awaiting operation. 

The observations given in Table 2 extend the findings of 
the first study of the Vermont cases, that paralysis is se- 
verest in the foot and diminishes toward the hip, and is 
severest in the shoulder and diminishes toward the hand. In 
that paper, however, one dealt with the relation of total to 
partial; here another class is available, and the ratio of 
severe to moderate bears out the same fact in two widely 
different classes of cases. 

Paralyzed Muscles Should not Lose Power. In the period 
covered by our observations (two months in the Vermont 
cases and longer in some of the Boston cases), it has ap- 
peared that the strength of affected muscles tends on the 
whole to remain stationary or to improve, and that a loss of 
strength is not to be expected, and when it occurs should be 
investigated. This statement rests on the study of forty-six 
cases of from one to five years' duration (three from 1911, 
one from 1913, forty-two from 1914) tested at an interval 
of two months or more ; 549 affected muscular groups were 
studied, 356 being under treatment by muscle training, and 
193 not under treatment. Seven per cent of the muscles 
under treatment showed a loss of power in this interval 
(twenty-five muscle groups in thirteen cases). In nearly all 



CERTAIN ASPECTS OF INFANTILE PARALYSIS 245 

Table 1. — Muscular Groups Showing Total Paralysis 

Vermont Boston 

Below knee 74 (82 per cent) 87 (82 per cent) 

Elsewhere 16 19 

Total 90 106 

instances this loss was to be accounted for by conditions 
known at the time of observation, such as fatigue, ill health, 
overuse, etc. In the muscles not under treatment there was 
some loss of power in 24 per cent (forty-seven muscle 
groups in twenty-one cases). In a large proportion of these, 
the conditions were such as to explain this observation. 

Overfatigue and its Detrimental Effects. The data as to 
the effect of muscular fatigue from overuse, over exercise 
therapeutically given and overmassage appeared to be im- 
portant, and certain clinical observations were formulated 
after the first series of clinics. A quotation follows : 

It has been repeatedly observed in my private practice 
that power might begin to return in a very faint degree to 
a muscle while under muscle training, and that with care 
this power would steadily increase, but if that muscle were 
exercised even very gently every day, that power would 
diminish or disappear, so that we exercise such muscles 
only once in three days at the outset, increasing the work 
most carefully. . . . 

Illustrative cases seem to me to show that much smaller 
degrees of overuse may be deleterious than is generally sup- 
posed. Probably any of us would agree that gross and per- 
sistent overuse of partly paralyzed muscles would be unde- 
sirable ; but it seems to me reasonable that in the early stage 

Table 2. — Distribution of Muscular Groups Showing 

Partial Paralysis 

Severe Moderate Severe Moderate 

Vermont Boston 
Lower extremity: 

Leg 115 109 203 161 

Thigh 89 61 101 76 

Hip 108 177 117 168 

Upper extremity: 

Shoulder and arm 91 87 58 80 

Forearm and hand 58 89 18 66 



246 INFANTILE PARALYSIS IN VERMONT 

of returning power, we should be exceedingly careful in the 
use of muscles in walking and in the use of heavy and pro- 
longed massage, much more careful than we are at present, 
if I may judge the practice of others by my own previous 
methods. 

This matter was confirmed and made more definite by the 
muscle test. Illustrative cases follow: 

Case 1. — A boy of 5, with the onset in 1914, was having at 
the time of the first test one and one-half hours of massage 
and one hour of muscle training daily. This was changed, 
and he was given one hour only of gentle muscular exercise, 
and the second observation showed a substantial gain of 
strength in all affected muscles, an illustration of the effect 
of too much treatment. 

Case 2. — A boy with the onset in 1914, in July showed 
partial paralysis of the left arm. He then began to milk ten 
cows daily, and in a month had lost strength in all of his 
left arm muscles except the biceps and triceps, which had 
gained slightly. The loss was greatest in the muscles of the 
forearm, which were of course those most exercised in milk- 
ing, an illustration of the effect of overuse of the muscles 
as a cause of loss of power in the overused muscles. 

In this matter of the study of the detrimental effect of 
fatigue and the beneficial effect of proper muscular exercise 
lies apparently one of the most important uses of the 
method. We need to know the dose of the remedy which we 
are using. 

Variations in General Muscular Strength. Children are 
subject to variations in muscular strength at different 
times, the whole scale of readings for both normal and af- 
fected muscles being sometimes decidedly higher or lower 
than their usual values ; but the raising or lowering of the 
whole scale while the relative strength of the muscles re- 
mains practically the same is apparently dependent on gen- 
eral conditions and does not affect the question of paralysis. 
During the great heat of September, 1915, a decided falling 
off in muscular strength was noted in several cases whose 



CERTAIN ASPECTS OF INFANTILE PARALYSIS 247 

normal scale was known, and observations were abandoned 
until it became cooler. 

Abortive Paralysis. That cases of- so-called abortive 
paralysis are often really cases in which paralysis exists, 
but is too slight to be detected by the ordinary examination, 
seems likely. Two observations bear on this point: 

In one family in Burlington, three children were similarly 
affected at about the same time. One showed a frank paraly- 
sis, and the other two did not, and were classed as abortive 
cases and showed nothing abnormal on the regular exami- 
nation. The muscle test revealed in one of these a decided 
weakness of the gluteal muscles of one leg, showing that the 
case was classed as abortive only because the regular exami- 
tion which was made was not delicate enough. In the other 
case, no departure was shown from the normal scale for a 
child of that age. This must therefore pass as a purely abor- 
tive case. 

The method has probably a diagnostic value in detecting 
in cases which have been regarded as possibly abortive a 
decided local muscular weakness too slight to be detected by 
the ordinary manual examination. 

Effects of Treatment. Muscle training as contrasted with 
simple massage showed that after a period of a few weeks, 
that is, when the treatments have been given for a sufficient 
time to demonstrate their effect, muscle training is superior 
to massage. This became evident after the third series of 
tests, and not after the second series, but a final conclusion 
cannot be presented on such short observation. 

Muscle Training. As to the effects of treatment, in the 
time available for observation the following facts appeared : 
The chance of improvement in affected but not totally para- 
lyzed muscles under expert treatment by muscle training 
was about 6:1, under supervised home exercises 3.5:1, un- 
der home exercises without supervision 2.8:1, while un- 
treated affected muscles in these patients showed an im- 



248 INFANTILE PARALYSIS IN VERMONT 

provement ratio of 1.9:1. These patients were nearly all 
affected in 1914, and represent cases at the end of the first 
year. They are all from the Vermont group and were treated 
there. 

Spontaneous Improvement. The ratio of 1.9:1 chance of 
improvement in untreated muscle groups is apparently 
partly spontaneous improvement, but this question is so 
very important in the matter of prognosis that it demands 
further analysis, because in most of these patients other 
muscles were being treated, and the figures to be quoted in- 
dicate that untreated muscles are favorably affected by the 
systematic exercise of other muscles. There were available 
in the Vermont series only seven patients on whom repeated 
muscle tests were made who were not receiving treatment 
because the prescription had not been followed by the par- 
ents. 

In these patients, in thirty-seven affected muscle groups 
there was improvement in nineteen and none in eighteen, a 
ratio of 1:1 of purely spontaneous improvement. These 
were all from the 1914 epidemic. The conclusion from this 
small group is that the treatment of one set of muscles by 
muscle training has a stimulating effect on muscles not un- 
der treatment. 

These facts may well give us courage to undertake a more 
vigorous treatment in late cases. Knowing that at the end 
of one year spontaneous improvement is by no means at 
an end, perhaps we may find that it extends much later than 
this when our observations have extended. These observa- 
tions on the recuperative power in the affected structures 
and how long it lasts appear to be of much practical impor- 
tance. 

Recovery of Poiver in Total Paralysis. The possibility of 
improvement in muscles totally paralyzed at the end of one 
year is also of much therapeutic importance. The following 
facts have been observed : Of forty-four totally paralyzed 



CERTAIN ASPECTS OF INFANTILE PARALYSIS 249 

muscles at the end of one year, 48 per cent (twenty-one) 
developed demonstrable power after two months of treat- 
ment. Of forty-four totally paralyzed, muscles not receiving 
treatment, 27 per cent (twelve) developed demonstrable 
power at the end of two months, which shows again that 
spontaneous improvement has by no means stopped at the 
end of a year. 

An observation shows how great this improvement may 
be and how late it may be obtained. A patient affected in 
1911 was under treatment for two months, beginning last 
July, by supervised home exercises. His unaffected muscles 
in this time gained 70 per cent, while his affected muscles 
gained this and 400 per cent more (470 per cent). These 
muscles were severely affected. This great gain at the end 
of four years by simple home exercises and the avoidance 
of fatigue is, it seems, most unexpected and encouraging. 

Types of Therapeutic Exercise. The usefulness of the 
method in throwing light on the value of different treat- 
ments is illustrated by the following observation: 

It was asserted by an English writer that the most help- 
ful exercise in infantile paralysis was to pull against the 
fully contracted muscle rather than to make resistance 
against the contracting muscle, technically that an eccentric 
exercise was physiologically more sound than a so-called 
concentric one. One observation showed that this advocated 
type of exercise was apparently harmful. A young girl with 
a moderately affected quadriceps muscle was given exercise 
of this newer type for two weeks, and lost 12.5 per cent of 
power; the regular exercises were then given for four weeks 
with a development of 50 per cent of power. It was not felt 
that it was proper to repeat this observation on other pa- 
tients, so that it must remain only as an unproved sugges- 
tion. 



250 INFANTILE PARALYSIS IN VERMONT 

OBSERVATIONS IN PRIVATE PRACTICE 

The private patients under observation from the practice 
of one of us, some of whom have been under observation 
since June, 1914, offer good material for study, as being 
under the most continuous observation. Instances of the 
practical applicability of the method in these cases are as 
follows : 

Case 3. — A girl of 10 had been affected since 1906, and 
when she came for treatment in 1911 she showed a mild 
equinus deformity of the .right foot. After various attempts 
to stretch this it was operated on in January, 1915, by ten- 
otomy, but the child, although improved, still walked poorly. 
Eight months later, in October, 1915, a muscle test showed 
decided weakness of the thigh flexors and extensors and an 
increasing weakness in the dorsal flexors of the right foot, 
which were getting weaker as the plantar flexors increased 
in strength. In October, 1915, exercises addressed to these 
muscles were prescribed, although the child had previously 
been doing exercises. In six weeks the mother reported that 
the progress since October had been far greater than at any 
time in the affection, and that the child could now "skip" 
on one foot and used herself very differently than she had 
ever done before, and the lameness had become very much 
less. An arm weakness had also been identified by the mus- 
cle test, for which exercises had been given with much bene- 
fit, an instance in which greater precision of treatment had 
demonstrated its greater usefulness. 

Case U- — A man of 22 was referred in the fourth week 
after his onset. He had involvement of the right leg and 
arm, walked with a limp and could not raise his right arm. 
The left arm appeared to be slightly weakened. Examina- 
tion by the usual method showed extensive weakness in the 
left arm, very little power in the right deltoid, and a general 
involvement of the right leg. His right arm was put in a 
sling, he was cautioned against much walking and the use of 
the arm, and weekly muscle tests were made, showing a gen- 
eral slow gain, but no therapeutic exercises were allowed at 
first. At a test, October 4, an increase of 50 per cent in the 
power of the right gastrocnemius muscle was observed, and 
on questioning it was found that he had been daily rising on 
his toes as a trial. This seemed to indicate that he was 
ready for therapeutic exercise, on which he then began with 



CERTAIN ASPECTS OF INFANTILE PARALYSIS 251 

success. The test, October 26, showed a loss of 25 per cent 
of power in the wrist and finger flexors of the right hand, 
and it was found on questioning that he had been writing 
too much. This was stopped, and on the following week a 
return of the former power was found in these muscles, an 
instance of the information afforded by the test in directing 
routine and defining treatment. 

Case 5. — A girl aged 8^, affected in 1913 with extensive 
paralysis of both legs, was walking with splints and 
crutches, and her muscle power was on the increase under 
daily muscle training. Nov. 18, 1915, there was a general 
loss of power in the legs. On questioning it was found that 
relatives had been visiting the family, and the child had 
been doing much more than usual, an instance of the dele- 
terious effect of local and general fatigue. 

These private patients are all tested at regular intervals, 
varying upward from one week, and it has been found that 
on the whole all are gaining in power and that the failure 
to gain in a special group or in general can be explained^ 
Muscles gain and lose rapidly, a week often showing marked 
changes. As a rule, the muscles receiving the most attention 
gain fastest, and treatment is constantly to be modified in 
response to changes in the muscle readings. The more pre- 
cise treatment is more satisfactory to those in charge of the 
case, and we believe of greater benefit to the patient. 

CONCLUSION 
No one realizes better than ourselves how very incom- 
plete this report is, but we are not justified in making it 
otherwise. There has not been a sufficient interval since our 
first observations to warrant us in making sweeping asser- 
tions as to the value of different treatments. We have under 
way, however, a series of observations on the effect of the 
different therapeutic measures and on the effect of braces, 
and plaster of Paris in operative cases. These will in due 
time be presented, and meantime we only desire to call at- 
tention to a method of observation which we believe to be 
useful and to certain general conclusions which we believe 
to be sound. 



THE SPRING BALANCE MUSCLE TEST* 

By Robert W. Lovett, M.D., Boston 

AND 

Ernest G. Martin, Ph.D., Boston 

A MEANS of estimating the quantitative strength of 
muscular groups has been devised and has proved of 
practical use. It was formulated for the purpose of 
giving not only a qualitative but a quantitative value to the 
examination. 1 ' 2 > 3 It deals with muscular groups rather than 
with individual muscles, and is likely to be of assistance, 
not only in the examination of the individual cases, but also 
in the study of the phenomena of the disease and possibly in 
diagnosis. Data obtained by its use have already been pub- 
lished. 4 

That such a quantitative test was necessary became evi- 
dent at the outset of the work in Vermont, references to 
which have just been given. 

The method is designed to test, under conditions of con- 
stant position and leverage, by a series of spring balance 
pulls, the power of the muscles which govern the movement 
of the limbs. The value of the test consists in the possibility 
of duplicating exactly the conditions of the first test at suc- 
ceeding ones, so that a definite idea of gain or loss in mus- 
cular strength can be registered in pounds. It is applicable 
for all tests of power in normal muscles, for determining 
loss or gain in power at stated intervals, and for the deter- 
mination of the degree of initial weakness in paralyzed 
muscles. It has been applied to infantile paralysis cases for 
one year in consecutive tests varying in frequency from ten 
days to three months. The result has been an accurate regis- 
ter of general gain and occasional loss in these cases under 



*Reprinted from The American Journal of Orthopedic Surgery, Vol. xiv, No. 7, pp. 
415-424, July, 1916. 

252 



THE SPRING BALANCE MUSCLE TEST 253 

treatment. The record has the advantage of representing 
concisely, in figures, the results of very detailed muscular 
examination and of presenting at later examinations the 
initial and intermediate conditions of the case. 

The accuracy of the test depends upon the training of two 
persons, an operator and an assistant, to coordinate the pull 
of the muscle and the registration of the pull on the scales, 
and upon the maintenance with exactness of the positions 
and leverage relationships outlined individually below. Ac- 
curate spring balance scales (No. 5 in Fig. 1)* are used, of 
4 sizes: 1 to 4 lbs., graded in ounces; 1 to 30 lbs., 1 to 50 lbs., 
and 1 to 100 lbs. The readings are taken to the half pound 
except on the ounce scale. 

The operator in general controls and maintains the cor- 
rect position of the subject, stimulates the subject to inner- 
vation, braces and guides the limb tested, and calls the 
moment of give in the muscle tested through watching the 
action of the muscle itself. The assistant makes the pull 
along lines accurately determined, beginning and stopping 
under the direction of the operator. The same command 
directs the muscular pull of the patient and the scale pull of 
the assistant. In all cases where the position of the assist- 
ant makes this possible, the scale reading is taken by him 
at the moment when the yielding in the muscle is called by 
the operator. Except under special circumstances, plantar 
flexion is the only reading which the operator is required to 
make. 

Twenty-two readings are taken, for each of which the 
best position of the subject for the accurate reading of the 
scales and for constant leverage in limb action has been de- 
termined experimentally. The order in which muscles are 
tested is immaterial except under conditions of weakness, 
but it is best that the order be constant so that all tests may 
duplicate each other as completely as possible. The appara- 
tus required is shown in the accompanying illustration and 

*See illustration facing page 254. 



254 INFANTILE PARALYSIS IN VERMONT 

referred to by the number on each piece, as they come into 
use in the description of the measurements themselves. 

In the lower extremity the test records the following 
movements: plantar flexion, dorsiflexion, inversion, ever- 
sion, adduction, abduction, hip extension, hip flexion, knee 
extension, knee flexion. The position of the operator and 
assistant in each movement is determined by their own con- 
venience for fulfilling the other conditions of the test. The 
operations of these two individuals and the position and 
action required of the subject, for the measurement of these 
movements, are as follows : 

Plantar Flexion. The subject lies on his back on a smooth 
table. The foot is braced against a three-to-one lever (No. 
1). The scale hook is inserted in the ring of the lever up- 
right. The lever must be adjusted so that the ball of the 
foot in maximum plantar flexion rests squarely upon the 
lever pad (No. 2), with the upright at an angle of from 60 
to 80 degrees to the table. The lever is held in position by 
C-clamps (No. 3). The pull is made by the assistant from 
the head of the table with the scale horizontal and in line 
with the leg being tested, and is increased in intensity to the 
point where the muscular resistance is overcome. To pre- 
vent slipping on the table, the shoulders of the subject are 
held by the hip-braces (No. 4). The muscle gives at about 
45 degrees of plantar flexion, with a rather sharp break in 
the resistance offered to the spring balance. All measure- 
ments of degrees are made to the plane of the table, unless 
otherwise specified. The operator guides the position of the 
foot, stimulates the patient to innervation, and calls the 
moment of break in the muscle to the assistant, for reading, 
or reads the scale himself. The reading of the scale must be 
simultaneous with this break. 

Dorsal Flexion. The general position of the subject is the 
same. The foot should be flush with the end of the table, to 
give freedom of action to the assistant in making the pull, 




Fig. 
the 



1. Apparatus used in muscle test, 
text. 



The numbers in the illustration are referred to 




Fig. 2. Test for dorsal flexion of foot. 



THE SPRING BALANCE MUSCLE TEST 255 

and should be slightly lifted and braced by the hands of the 
operator, which encircle the ankle. The leather loop (No. 6) 
is placed across the toes at their metatarsophalangeal joints. 
With the foot in maximum dorsiflexion, the assistant makes 
the pull at right angles to the plantar surface of the foot, 
lowering the scale to maintain this angle as the foot gives. 
The muscle is watched by the operator, and the moment 
when it gives, called to the assistant, who takes the scale 
reading. (Fig. 2.) 

Inversion, Body position of the subject the same as in 
dorsal flexion. The loop is across the inner surface of the 
great toe joint. The ankle is braced by the hands of the 
operator. With the foot at right angles to the leg, the foot 
is inverted and adducted as far as possible without inward 
rotation of the leg. The pull is opposite in direction to the 
muscular contraction, horizontal, and in the same vertical 
plane as the foot. The assistant swings the scale so as to 
maintain this relationship as the foot gives. The reading is . 
taken by the assistant at the moment when the operator 
calls the break in resistance of the foot. 

Eversion. General position as in dorsal flexion. Loop at 
the outer surface of the distal end of the fifth metatarsal. 
The foot is at right angles to the leg and is everted and ab- 
ducted as far as possible without outward rotation of the 
leg. The pull is horizontal and in the same vertical plane 
as the foot, with a scale swing to maintain this position. 
The break is called and read as above. 

Adduction of the Leg. No change in general body posi- 
tion of the subject. Two hip-braces (No. 4) are placed in 
line with the crest of the ilium on each side of the pelvis and 
attached to the table with the C-clamps. With one hand in 
the popliteal space and the other below the heel, the opera- 
tor gently supports the weight of the leg, raises the leg 
about fifteen degrees from the table, and maintains the foot 
vertical to prevent leg rotation. The subject contracts the 



256 INFANTILE PARALYSIS IN VERMONT 

inner muscles of the thigh so as to swing the leg inward 
across the median line about fifteen or twenty degrees. This 
angle of contraction is a matter of comfort to the subject 
and varies with the individual. The angle of elevation of the 
leg from the table must be constant. The subject, during the 
pull, braces the trunk with the hands by pushing against 
the clamps of the hip-brace on the side opposite to that 
being tested. The loop is placed just above the internal mal- 
leolus. The pull is outward, horizontal, and at right angles 
to the leg. It must swing so as to preserve this angle as the 
leg gives. The operator calls for the reading as the leg be- 
comes exactly parallel to the median plane of the body. This 
reading can be taken in the same fashion with the loop at 
the knee just above the patella. The power here, with allow- 
ance for minor individual variations in leg length, doubles 
the ankle pull through halving the distance of the measur- 
ing spring balance from the fulcrum. The knee pull is used 
where the quadriceps is weak and it is difficult for the sub- 
ject to maintain knee extension while making the adductor 
pull from the hip. 

Abduction of the Leg. The details of position and bracing 
in this pull differ only in the direction of the muscular ac- 
tion, which reverses the bracing and the positions of the 
operator and assistant. The loop is just above the external 
malleolus. The subject contracts the muscles which abduct 
the hip so as to swing the leg outward from the median 
plane at an angle of thirty or forty degrees, according to 
individual comfort. The pull is inward, horizontal and at 
right angles to the leg. This angle and the angle of fifteen 
degrees of leg elevation must be maintained constant 
throughout the pull, exactly as in adduction. The operator 
calls for the scale reading as the leg becomes parallel to the 
median plane. The test is made at the knee where the quad- 
riceps is weak. 



THE SPRING BALANCE MUSCLE TEST 257 

Hip Extension. The subject lies on the side opposite to 
that to be tested, with the hips directly one above the other. 
The abdomen is braced against the hip-clamp used in ab- 
duction and adduction. At the lower end of the table, two 
C-clamps, across which a small board is placed for comfort, 
are used by the subject as a brace. He pushes against this 
with the foot of the leg not being tested, to secure steadi- 
ness. The trunk is braced forward, by the subject, by hold- 
ing to the edge of the table with the hands. The operator 
maintains the position of the abdomen against the hip brace 
with one hand, and with the other supports the weight of 
the leg to be tested, and keeps the leg parallel to the table. 
The loop is at the knee across the popliteal space. The leg is 
placed in maximum extension with the knee straight. The 
direction of pull of the balance is slightly less than 90 de- 
grees to the leg, being deflected towards the trunk, and is 
exerted horizontally. The angle of the pull must be con- 
stant throughout the movement. The operator calls for the 
reading as the leg crosses the line of the trunk, or if the 
muscle gives before this, the reading is taken when the mus- 
cle yields. 

Hip Flexion. Side position and foot brace, as for hip ex- 
tension. The small of the back is against the hip-brace. The 
subject maintains the rigidity of the trunk by pushing with 
the hands against the opposite hip-brace. The operator sup- 
ports the leg parallel to the table, with one hand at the knee 
and the other at the ankle. The loop is at the knee just 
above the patella. The knee is well bent, and the thigh is 
flexed above the right angle. The pull is horizontal and as 
near as possible at right angles to the femur. The reading 
is taken when the muscle gives. 

Knee Extension. The subject lies on the face on the table 
with the lower leg flexed at the knee and vertical to the 
table. The loop is at the ankle just proximal to the malleoli. 
The assistant stands at the head of the subject, bracing the 



258 INFANTILE PARALYSIS IN VERMONT 

shoulder with one hand. The pull is horizontal, and parallel 
to the median plane. The operator braces the knee on the 
table with one hand, and with the other at the ankle limits 
the extension. The movement begins from the perpendicular 
position, and the effort of the subject to extend the leg and 
the pull of the assistant must start simultaneously at the 
command of the operator. Both pulls should begin slowly, 
and it is essential that the muscle pull and the pull of the 
spring balance should develop together in this test. The 
leg is not permitted to extend from the perpendicular posi- 
tion further than to within 75 degrees of the table. Greater 
extension than this changes the leverage and produces in- 
accuracy. The pull of the assistant continues until the knee 
is drawn back to the original position, the operator calling 
for the scale reading exactly as the leg crosses the perpen- 
dicular line. The quadriceps test is the most accurate of 
all tests as to repetition, but also the most liable to error if 
over-extension is permitted, before the balance pull begins 
to draw the leg back to the vertical position. 

Knee Flexion. General body position of the subject and 
brace by the operator the same. Ankle loop reversed in 
direction and the assistant at the foot of the table. The sub- 
ject places the leg in maximum flexion. The pull is hori- 
zontal and rotation of the hip should be minimized. The 
operator calls for the scale reading as the lower leg crosses 
the perpendicular position. If the reading is taken with the 
leg more than fifteen degrees beyond the perpendicular, 
accuracy is destroyed through change of leverage. 

This group of leg tests can be made in half an hour where 
the subject responds easily to directions and the operator 
and assistant are accustomed to coordinate work. Every 
reading is repeated as a check. The readings agree very 
closely unless there is an error in technique. In the first test 
the pull generally rises slightly on the repetition because the 



THE SPRING BALANCE MUSCLE TEST 259 

subject understands the requirements of the movement bet- 
ter the second time it is made. 

In the upper extremity the test records the following 
movements: Pectoralis, latissimus dorsi, anterior deltoid, 
posterior deltoid, forearm extension, forearm flexion, wrist 
extension, wrist flexion, finger extension, finger flexion, 
thumb adduction, thumb abduction. In all the movements, 
the break is called by the operator and the scale read by the 
assistant. For the first four movements the loop is at the 
elbow just above the condyles of the humerus. 

Pectoralis. The subject stands or sits, with the shoulders 
and the hips in the same vertical plane. If standing, he 
braces the thigh well against the table to prevent loss of 
balance. The arm is drawn as far as possible across the 
front of the body, just clearing the trunk, with the forearm 
in pronation. Any brace of the body with the opposite arm 
is permissible which does not disturb the plane of the shoul- 
ders and hips. The pull is horizontal and outward posterior- 
ly at an angle of 30 degrees to the lateral plane of the body. 

Latissimus Dorsi. The subject stands or sits, as above, 
the fist is closed, and with the dorsum of the hand towards 
the back, the arm is drawn as far as possible, across, behind 
the body, just clearing the trunk. The pull is horizontal and 
outward anteriorly at an angle of 30 degrees to the lateral 
plane. 

Anterior Deltoid. Positions of the subject the same. The 
opposite hand holds to any support which does not elevate 
the shoulders. The arm being tested is raised to the level 
of the shoulder, and brought forward to an angle 30 degrees 
from the lateral plane of the trunk. The pull is backward 
and downward, establishing an angle of 60 degrees with the 
upper arm, and maintains this angle as the arm gives. 

Posterior Deltoids. The subject stands or sits, as in the 
other shoulder tests. The arm is raised to the level of the 
shoulder posteriorly at an angle of 30 degrees to the lateral 



260 INFANTILE PARALYSIS IN VERMONT 

plane of the trunk. The pull is forward and downward, 
establishing an angle of 60 degrees with the upper arm, and 
maintains this angle as the arm gives. 

Forearm Extension. The subject lies on the back, with 
the arm at the side, and the forearm perpendicular to the 
table, against which the elbow rests. The hand is closed 
with the thumb pointing to the shoulder. The loop is at the 
wrist just proximal to the styloid process of the ulna. The 
assistant stands at the head of the table and braces with 
one hand the shoulder of the side to be tested. The operator 
braces the elbow on the table with one hand, and with the 
other at the wrist limits the extension of the forearm. The 
pull is horizontal. At the direction of the operator, the ex- 
tension of the forearm and the pull of the assistant start 
together slowly. Extension is permitted to from 5 to 15 
degrees from the perpendicular, and is overcome by the as- 
sistant. The call for the reading of the scale is made just as 
the forearm crosses the vertical line. 

Forearm Flexion. No change in the position of the sub- 
ject nor the bracing of the operator. Loop just proximal 
to the styloid process of the radius. The forearm is placed 
in maximum flexion with the elbow on the table, the hand 
closed, and the thumb pointing toward the shoulder. When 
the muscular power requires it, the foot brace described in 
hip extension is used in the same fashion by the subject to 
prevent slipping during the movement. The pull is horizon- 
tal. The operator calls for the scale reading as the forearm 
crosses the perpendicular line. 

Wrist Extension. The subject extends the entire arm 
laterally and anteriorly, according to individual comfort. 
With the palmar surface of the hand vertical and the fin- 
gers extended, the wrist is put in maximum extension. The 
operator encircles the wrist with his hands, bracing the 
subject's arm in the extended position. The small loop (No. 
7) is across the dorsum of the hand, just distal to the meta- 



THE SPRING BALANCE MUSCLE TEST 261 

carpals. The pull is exerted horizontally and at an angle 
slightly less than 90 degrees to the hand, being deflected to- 
wards the wrist. The angle of pull must be constant, and to 
secure this the assistant swings the scale through an arc as 
the hand gives. The accuracy of the reading depends abso- 
lutely upon maintaining the direction of the pull and upon 
the correct placing of the loop, and is most important in this 
and the three following tests. 

Wrist Flexion. With the arm well away from the side, the 
subject flexes the elbow according to comfort. With the 
fingers flexed at right angles to the palm, and the palmar 
surface of the hand in the vertical plane, the subject puts 
the wrist in maximum flexion. The small loop is across the 
palm at the crease formed by the finger flexion. The opera- 
tor braces the wrist and arm in this position, encircling the 
wrist with both hands. The pull is horizontal and at an 
angle slightly less than 90 degrees to the dorsal surface of 
the hand. The angle of the pull must be maintained by an 
arc swing of the scales. 

Finger Extension. The subject extends the arm as for 
wrist extension. The hip-brace is attached lengthwise to 
the side of the table. The palm of the hand well below the 
palmar crease is braced by the operator against the curved 
Upright of the brace. The small loop is across the fingers 
dorsally, just proximal to the first interphalangeal joint. 
The pull is horizontal, and at an angle slightly less than 90 
degrees to the extended fingers and deflects towards the 
wrist. 

Finger Flexion. The position of the subject and the brace 
by the operator are the same. The small loop is placed across 
the fingers on the palmar surface, just proximal to the first 
interphalangeal joint. The palmar surface of the hand is 
vertical against the brace. The pull is horizontal and slight- 
ly less than 90 degrees to the proximal phalanges. The de- 
flection is towards the dorsum of the hand. 



262 INFANTILE PARALYSIS IN VERMONT 

Thumb Adduction. With the palmar surface down and the 
hand horizontal, the operator braces the extended fingers 
with one hand and the wrist with the other. The small loop 
is placed at the interphalangeal joint of the thumb. The sub- 
ject adducts the thumb as far as possible under the palm. 
The pull is horizontal and at right angles to the thumb 
joint. The call for the reading is made by the operator just 
as the thumb appears from under the hand. 

Thumb Abduction. General position of the hand and 
brace by the operator the same as for the preceding test. 
The subject abducts the thumb in the same horizontal plane 
as the hand. The position of the small loop is identical with 
that of adduction, but reversed in direction. The pull de- 
flects downward from the horizontal just enough to escape 
the palmar surface of the hand. It is exerted at right angles 
to the thumb. 

The complete arm test requires half an hour, and each 
reading is repeated as a check. 

References 

Martin, E. G., and Lovett, R. W.: A Method of Testing Muscular 
Strength in Infantile Paralysis. Jour. A. M. A., October 30, 1915. 

2 Lovett, R. W. : The Treatment of Infantile Paralysis. The Newer 
Aspects of the Problem, with Certain Conclusions Drawn from the 
Vermont Epidemic. Jour. A. M. A., June 26, 1915. 

3 Lovett, R. W., and Martin, E. G. : Infantile Paralysis in Vermont. 
A Report of the Progress of Cases Between January, 1915, and July, 
1915. Vermont State Medical Journal, February, 1916. 

4 Lovett, R. W., and Martin, E. G. : Certain Aspects of Infantile 
Paralysis, with a Description of a Method of Muscle Testing. Jour. 
A. M. A., March 4, 1916. 



A PLAN OF TREATMENT IN INFANTILE 

PARALYSIS* 

Robert W. Lovett, M.D. 

THE successful treatment of infantile paralysis re- 
quires that the surgeon should have in his mind a 
definite plan covering all the phases of the disease, a 
plan based on the pathology in its various phases. We have 
at the outset a virulent acute affection with a high mor- 
tality, then comes a period of two years, during which we 
try to restore to their highest efficiency the affected muscles, 
and finally we meet in the later and so-called stationary 
stage of the affection the question of correcting deformity 
and restoring or improving function by operative measures. 
Few affections offer a wider range of requirements from a 
therapeutic point of view, and if when we are treating the 
first stage we bear in mind what may happen to the patient 
in the third stage, we shall treat the early stages better. 

The muscle test spoken of in the paper is a means of 
quantitatively estimating the strength of muscles by means 
of their pull against a spring balance, and is not only useful 
in locating the existence of weakness in different muscular 
groups, but offers a means of estimating the gain or loss in 
muscular strength under given conditions. 1 
The stages of the disease are as follows : 
1. The stage of onset begins with the acute attack, and 
may be assumed to end when the tenderness has disap- 
peared, a duration in general of from four weeks to three 
months. A hemorrhagic myelitis is present, widespread, 
and affecting chiefly the centers of motion. The centers of 

*Read before the Section on Orthopedic Surgery at the Sixty-Seventh Annual Session of 
the American Medical Association, Detroit, June, 1916. Copyright 1916, Am. Med. Assn. 
and reprinted by permission from the Jour, of the A. M. A., Aug. 5, 1916, Vol. LXVII. 

1. Martin, E. G., and Lovett, R. W. : A Method of Testing Muscular Strength in Infan- 
tile Paralysis, The Journal A. M. A., Oct. 30, 1915, p. 1512. 

263 



264 INFANTILE PARALYSIS IN VERMONT 

sensation are also involved, the posterior root ganglia in 
experimental pathology showing the first changes, and the 
existence of tenderness must be accepted as evidence of an 
active process in the spinal cord. During this tenderness it 
is not physiologically reasonable to excite the peripheral 
connections of the affected nerve centers by massage and 
electricity. The former at times causes great increase of 
pain and soreness, and has nothing to recommend it at this 
stage, and there is no evidence whatever to show that elec- 
tricity is of any value at this stage. Rest is the physiologic 
requirement, and the method of treatment that in practice 
works best, and the growing tendency to omit meddlesome 
therapeutic measures at this stage is hopeful. There is evi- 
dence that the use of hexamethylenamin in monkeys dimin- 
ishes the risk of infection, but has no effect after the paraly- 
sis has occurred, and as the drug in moderation is harmless, 
it is extensively used in this stage. There is no serum or 
drug or proceeding that is known to abort the affection or 
limit the paralysis, although Netter of Paris has admin- 
istered intraspinal injections of the blood of recovered per- 
sons with, he believes, benefit, but only in a small series of 
cases, and the proceeding is as yet wholly in the experi- 
mental stage. 

During this stage the patient should be kept quiet. Joints 
will not stiffen, hopeless muscular atrophy will not occur, 
and by this proceeding the damaged cord will have the best 
chance to repair, and repair to the highest degree is desir- 
able. 

Deformities should be prevented by keeping the feet at 
right angles to the legs to avoid the most common deform- 
ity, a dropped foot. Toward the end of this period immer- 
sion in a warm salt bath is desirable and permits a degree 
of exercise to the affected limbs. Scoliosis begins frequently 
in this stage, and is often overlooked. 



TREATMENT OF INFANTILE PARALYSIS 265 

2. The second stage, or phase of convalescence, may be 
assumed to begin with the disappearance of the tenderness 
and to last for two years or more, at the end of which 
period the disease has become more or less stationary. The 
pathologic condition at this stage formulates the treatment. 
The hemorrhagic myelitis is subsiding, the perivascular in- 
filtration which has blocked some of the spinal arteries is 
being absorbed, and these cells are resuming their function 
little by little, inflammatory products are being absorbed, 
and the clinical manifestation of these processes is ex- 
pressed in what we all recognize as "spontaneous improve- 
ment," which begins when the tenderness disappears and 
lasts almost indefinitely, diminishing in its rate as the 
months pass. 2 

The clinical manifestation of the pathologic process is a 
motor impairment of muscles, widespread and in general 
erratic, more often a weakening than a complete paralysis. 
In the Vermont series of cases, 3 manual examination of 
muscles showed the proportion between partial and total 
paralysis to be as 2Xfa :1, and the more delicate muscle test, 2 
which detects slighter grades of weakening, found the pro- 
portion to be as 9:1. 

Our problem at this stage therefore is to restore the max- 
imum function to affected muscles, and to study carefully 
the measures most likely to accomplish this end. This point 
of view becomes especially important when we realize that 
muscular weakening is much more common than complete 
loss of power. It is a very important matter to the patient 
with a gastrocnemius muscle with only 20 per cent of the 
normal power whether that muscle ultimately regains 40 
per cent or 90 per cent of its proper strength. 

It becomes necessary then to consider those measures 
which are likely to prove most useful in bringing about the 

2. Lovett, R. W., and Martin, E. G. : Certain Aspects of Infantile Paralysis, The Journal 
A. M. A., March 4, 1916, p. 729 

3 Lovett, R. W. : The Treatment of Infantile Paralysis, The Journal A. M. A., June 
26, 1915, p. 2118. 



266 INFANTILE PARALYSIS IN VERMONT 

maximum improvement, and to comment on conditions like- 
ly to prove detrimental. 

AMBULATORY TREATMENT 

When the acute stage is over it is on the whole desirable 
to get the patient on his feet, that is, to institute ambulatory 
treatment. Prolonged recumbency is for a child unnatural 
and undesirable physiologically and mentally. The sitting 
position not varied by the upright position is of all most 
likely to lead to flexion deformity of the hips and knees and 
to dropped feet. The upright position induced by ambula- 
tory measures is desirable not only because it antagonizes 
the conditions mentioned, but because the effort to balance 
on the feet instinctively excites to effort a large number of 
muscles not otherwise to be reached, and is a valuable form 
of "muscle training," a therapeutic measure to be mentioned 
later. On the other hand, this method is open to the objec- 
tion of possibly fatiguing convalescent muscles and some 
authors advocate prolonged recumbency. In my opinion, the 
ambulatory method with proper avoidance of fatigue is on 
the whole the best to be pursued at the end of two or three 
months. 

If the patient can walk without braces, so much the bet- 
ter. If apparatus is needed to permit ambulatory treatment 
it should be used, but worn only in walking and in early 
cases not continuously. The most commonly required form 
of apparatus is the Thomas caliper splint, which serves to 
keep the knees straight. Crutches may or may not be re- 
quired. A good general rule with regard to apparatus is 
that it should be used when the patient cannot stand with- 
out it, or if in standing or walking a position of deformity 
is assumed, because deformity leads to stretching of soft 
parts, and if persisted in to permanent bony changes. 

The two conditions most frequently overlooked which 
lead to serious results are weakening or paralysis of the 



TREATMENT OF INFANTILE PARALYSIS 267 

abdominal muscles and scoliosis. In the writer's opinion, 
when these occur the use of a cloth corset or plaster jacket 
is imperative from the time that the first stage is over. 

A patient who has been long in bed when first put on his 
feet is often unable to balance even if he has sufficient mus- 
cular strength, and the problem of cultivating equilibrium 
in these cases must be taken up by itself and patiently per- 
sisted in. 

Having thus formulated the matter of ambulatory treat- 
ment, the question next arises as to those therapeutic meas- 
ures which are likely directly to have a favorable effect on 
the muscles. These are (1) massage, (2) electricity, (3) 
heat, and (4) muscle training. 

1. Massage is of value because it empties the veins and 
lymphatics and thus promotes the flow of blood to the limb, 
and because it apparently retards muscular atrophy and 
promotes muscular tone. More than this, however, is not to 
be expected of it. It does not promote the passage of nervous 
impulses from brain to muscle, and its action must be con- 
sidered purely local. Given roughly or for too long a time 
it is detrimental and retards progress, and its overuse is 
probably responsible for much harm. 

2. Electricity has been much discussed, and in the ab- 
sence of definite data one must fall back on personal experi- 
ence. Faradism causes a mild muscular contraction, and 
may be a useful form of gentle exercise. It is disagreeable, 
and to young children often a source of terror. The gal- 
vanic and newer forms of currents are assumed to have a 
beneficial effect in general, but in many years' experience 
in treatment with and without electricity (used often on 
one side of the patient only with the other side as a control) 
the writer has never been able to satisfy himself in a single 
case that it was of any value. Certain recent experimental 



268 INFANTILE PARALYSIS IN VERMONT 

work on the retardation of atrophy in denervated muscles 
is of interest: 4 

It is practically certain that if electrical stimulation has 
a beneficial effect, the optimal effect will be with that cur- 
rent which is strong enough just to cause contraction. In 
the ordinary methods of stimulating muscles through the 
skin, whether by unipolar or bipolar methods, with currents 
of long or short duration, the intensity of the current^is 
much greater in the superficial than in the deep fibers, and 
we think it doubtful whether the latter can be stimulated 
without using currents injurious to the former. 

That the use of electricity has done much harm is un- 
doubted, because not only is the use of strong currents ad- 
mittedly injurious, but the routine use of electricity often 
deludes the physician and parents into thinking that the 
child is receiving adequate treatment while measures of 
admitted value are neglected. 

3. Heat is of value either as radiant heat from electric 
bulbs or by some form of oven, because it raises the tem- 
perature of the limb, and thus offers more favorable con- 
ditions for muscular contraction, and because it stimulates 
the flow of blood to the limb. 

4. Muscle training is in the writer's opinion the measure 
of the greatest value at this stage, and this stage is im- 
portant because, however operative the surgeon may be, he 
will during these two years use nonoperative treatment. 

Muscle training attempts to drive an impulse from brain 
to muscle to enable it if possible to open up new paths 
around affected centers in the cord. The connection between 
these centers with each other and between the centers and 
the muscles is most extensive and complex, 5 and the facts 
given as to the predominance of partial paralysis show 
that as a rule the entire nervous control of a given muscle 
is not wiped out as a whole, but only in part. On this basis 

4. Langley and Kato : Jour. Physiol., 1915, xlix, 432. 

5. Bing: Compendium of Regional Diagnosis in Affections of the Brain and Spinal 
Cord, New York, 1909. 



TREATMENT OF INFANTILE PARALYSIS 269 

rests the claim of muscle training, a measure which in the 
opinion of the writer is one of the most powerful factors in 
determining ultimate muscular function. 

As to the efficacy of this treatment, the following data 
were observed in Vermont by means of the muscle test. The 
period covered was three months : 

The chance of improvement in affected but not totally 
paralyzed muscles under expert treatment by muscle train- 
ing was about 6 to 1, under supervised home exercises 3.5 
to 1, under home exercises without supervision 2.8 to 1, 
while untreated affected muscles in these patients showed 
an improvement ratio of 1.9 to 1. These figures represent 
cases at the end of the first year. They are all from the 
Vermont group and were treated there. 

In order to determine just what might be expected from 
the treatment by muscle training an analysis was made of 
the progress of all patients in my private practice during 
the past winter who had had two successive muscle tests 
at times widely enough separated to warrant any conclu- 
sions as to their progress. No cases were omitted, and the 
patients, as indicated in the accompanying table, are divided 
into two classes, those coming daily to the office for treat- 
ment by an expert assistant, and those whose treatment by 
muscle training was prescribed at the office but carried out 
at home by some unskilled person. 

One difficulty presented itself in the analysis. Certain 
cases were regarded as having no power at all at the first 
examination, and in these cases for purposes of computing 
it was assumed that the children had power of one-eighth 
pound, not sufficient to move the scale. It was found that a 
child with one-fourth pound of muscle power would, how- 
ever, move the scale, and these were the ones that were 
noted at the initial observation as having a trace of power. 
The percentage gain of each muscle was then reckoned, and 
the figure given in the table represents the average percent- 
age of gain of all the muscles. If the paralysis was uni- 



270 



INFANTILE PARALYSIS IN VERMONT 
Result op Muscle Training 









Average 


Average 












Total 


Monthly 








Time 


Interval 


Gain 


Gain 








Since 


Covered 


of 


of 


Apparatus 


Region 


Age 


Attack 


by 
Tests 


Affected 

Muscles, 

per 

Cent. 


Affected 

Muscles, 

per 

Cent. 


Worn 


Recorded 



Patients treated daily at office by skilled assistants 



22 


1 mo. 
3 mos. 

3 mos. 
21 mos. 

4 mos. 
15 mos. 

3 mos. 


6 mos. 

5 mos. 

6 mos. 
10 mos. 

4 mos. 

7 mos. 
6 mos. 


197 

82 

146 

200 

688 
702 
184 


24 
16 

21 
20 

172 

100 

30 


Sling 


Arms 


8 
9 


Corset, crutches, 

braces 
None 


Legs 

Legs 
Legs 

Legs 

Legs 

Legs 


9 
14 

8 
8 


Plaster jacket, 
crutches, braces, 

Corset, braces, 
crutches 

Corset, braces, 
crutches 

Corset 







Patients treated at home by relatives or nurses (unskilled) 



10 


1 yr. 


6 mos. 


13 


2 




Ueg 


30 


5 mos. 

6 yrs. 
2M yrs. 


1 mo. 
3 mos. 


44 
12 


44 

4 


Sling 


1 arm 


24 


None 


Ueg 
Ueg 


10 


8 mos. 


108 


13.5 


Corset, plate .... 


11 


6 yrs. 


5 mos. 


89 


17 


Plaster jacket, 
braces 


Legs 


4 


1 yr. 
9 yrs. 


7 mos. 
2 mos. 


30 
33 


4 
17 


Brace 


1 leg 


11 


None 


Arm and 






leg 


10 


3 yrs. 


4 mos. 


16 


3.5 


High heel 


lleg 


10 


5 yrs. 


7 mos. 


None 


None 




lleg 


14 


8 yrs. 


8 mos. 


67 


8 


Plaster jacket, 
brace 


lleg 


16 


2 mos. 


3 mos. 


620 


206 


Brace and 
crutches 


lleg 


8 


1 yr. 


7 mos. 


202 


28 


Braces and 
corset 


2 legs, 2 
arms 



TREATMENT OF INFANTILE PARALYSIS 271 

lateral, the per cent of gain in the unaffected limb was de- 
ducted from the gain of the affected side and only the excess 
counted. 

Deformity occurs in many forms, but the therapeutics of 
it are easily formulated. In the earlier stages it is generally 
to be avoided by preventing persistent malposition. If fixed 
deformity exists it must be removed before undertaking 
treatment, nonoperative or operative. The neglect of this 
rule is one of the most frequent causes of failure of treat- 
ment. Deformity is corrected by stretching by hand, by 
plaster or by apparatus, by forcible stretching under an- 
esthesia, by tenotomy, fasciotomy, myotomy or osteotomy, 
the mildest measure that will suffice being the soundest and 
best. 

Stretched muscles are at a great disadvantage so far as 
recovery goes, as pointed out years ago by Charles Fayette 
Taylor, and later by Robert Jones. The best example of 
this is in gastrocnemius paralysis, most efficiently treated - 
when it exists alone by very high heels, throwing the mus- 
cle out of use and preventing stretching. 

Fatigue and overtreatment by massage and exercises are 
detrimental factors of the highest importance too little at- 
tended to. This has been especially brought out by the 
studies by means of the muscle test, which have shown that 
a surprisingly small amount of exercise was detrimental to 
convalescent muscles, and in some muscles returning power 
has been wholly abolished by overuse. The advice often 
given to use affected limbs as much as possible is in the 
opinion of the writer the worst advice that can be given. It 
is difficult to underuse such muscles, but fatally easy to in- 
jure them by overuse. 

3. The third stage is generally called the stationary stage, 
and begins about two years after the onset. The require- 
ments of the preceding stage as to the care of the muscles, 
etc., still exist, but are less urgent. In cases which have not 



272 INFANTILE PARALYSIS IN VERMONT 

been properly treated earlier, muscle training may accom- 
plish much, even in cases of long duration. The require- 
ments as to apparatus remain much the same throughout. 

The dominant requirements of this stage are operative, 
and are first the correction of deformity, a matter already 
discussed, and second, operations to improve function and 
secure stability. 

Operations to improve function are by all experienced 
surgeons deferred until at least two years after the on- 
set (and by some men several years) in order to permit 
recovery of muscular power to become as great as possi- 
ble and to enable the mechanical conditions in the af- 
fected limb to become clearly defined before operating. 

Tendon transplantation 6 is the most brilliant of these 
measures. It implies the existence of one comparatively 
normal muscle in the region to be operated on. Simple 
operations have replaced complicated ones, periosteal in- 
sertion is used, silk extensions are in common use, ten- 
dons are passed in the subcutaneous tissue, and prolonged 
after-treatment is the rule, unrestricted use not being 
allowed under one year from operation. 

Nerve transplantation, 7 which is the other operation to 
improve function, has not been generally used because the 
most skillful operators in this field have not reported a large 
proportion of satisfactory results, and also for the reason 
that the operation is advised at so early a period in the 
disease. 

OPERATIONS TO IMPROVE FUNCTION 

Arthrodesis 8 has lost favor because of the entrance in the 
field of operations yielding better functional results, and 



6. Lange: Miinchen. med. Wchnschr., 1902, No. 1; Ztschr. f. orthop. Chir., xxix; Ztschr. 
f. artzl. Fortbild., 1905, 22. Vulpius: Deutsch. med. Wchnschr., 1912, xxxvi. Lovett: 
Boston Med. and Surg. Jour., 1910. 

7. Spitzy : Handbuch der Kinderheilkunde, Lange and Spitzy, Leipzig, 1910, p. 310 ; 
Ztschr. f. orthop. Chir,, xiii. Osgood (review) : Boston Med. and Surg, Jour., June 30, 
1910. Vernicchi: Arch, di ortop., 1910, xxvii, 337. Kilvington: Brit. Med. Journ., April, 
1907. Deroux: Lyon chir., December, 1912. 

8. Jones, Robert: Tr. Int. Cong. Surg., 1909, xvi. 



TREATMENT OF INFANTILE PARALYSIS 273 

the most experienced surgeons do not favor it in the ankle 
until after late childhood, if at all. At the knee it is always 
questionable and dangerous in early childhood. In the hip 
it is desirable, but often unsuccessful. 

Astragalectomy, 9 on the other hand, has gained in favor, 
and although originally introduced by Whitman only for 
talipes calcaneus, it is now widely used where arthrodesis 
would formerly have been performed. A transverse section 
of the foot devised by Davis 10 deserves mention as being 
useful in calcaneus deformity. 

Silk ligaments 11 are used because silk left in the tissues 
becomes coated with fibrous tissue and serves as a ligament. 
This is especially used to correct the dropped foot by pass- 
ing several strands of silk anteriorly from the tibia to the 
tarsus. It is a brilliant operation when successful, but has 
often failed, probably because too little silk has been used. 
In a child of 8 or 10 one should use six to eight strands of 
No. 12 silk. 

Tendon fixation 12 or tenodesis has lately been revived by 
Gallic, and is extensively used. The paralyzed tendons are 
sewed into grooves in the bone, thus being transformed into 
ligaments, to correct deformity and check excess of motion. 
Stretching may occur, but the operation seems to have a 
field of usefulness. 

Two of these operations are frequently combined, as, for 
example, tendon transference and silk ligaments, and simi- 
lar instances. 

SUMMARY 

This paper is a plea for a definite uniform plan for the 
treatment of infantile paralysis in all of its stages, for a 
direct attack on the disease based on its pathology, and for 
persistency and precision in that therapeutic attack, with 

9. Whitman, R. : Ann. Surgery, February, 1908 ; Am Jour. Med. Sc, November, 1901. 

10. Davis, G. G. : Am. Jour. Orthop. Surg., October, 1913, p. 240. 

11. Lange: Munchen. med. Wchnschr., 1906, li ; Ztschr. f. orthop. Chir., xvii, 266. 

12. Gallie : Am. Jour. Orthop. Surg., January, 1916. 



274 INFANTILE PARALYSIS IN VERMONT 

special care as to the avoidance of fatigue from overexer- 
cise or overtreatment. It is the belief of the author that no- 
where in orthopedic surgery does the difference between 
the best and indifferent treatment have more effect on the 
ultimate result than in this disease. 
234 Marlborough Street. 



HISTORY OF THE AFTER-CARE OF 
POLIOMYELITIS IN VERMONT 

By Robert W. Lovett, M.D. 

THE history of the after-care of poliomyelitis in Ver- 
mont is of interest as it was the first state-wide work 
undertaken anywhere in this country and is today 
the most fully developed scheme for the after-care of polio- 
myelitis on a state- wide scale which exists. 

In 1914 there occurred in the northern part of Vermont 
an epidemic of great severity, with a very high incidence 
across the northern half of the state, and from this epidemic 
306 cases were reported. Undoubtedly not all the cases were 
reported, but of those that were the mortality rate was 23 V2 
per cent, so that 226 cases at the close of this epidemic were 
left with varying degrees of paralysis. This was the condi- 
tion that faced the State Board of Health at the close of the 
epidemic and it was obvious that, unless something was 
done in the way of treatment, the amount of resulting dis- 
ability and disabling deformity would be very great. 

Vermont is essentially an agricultural community with 
comparatively few inhabitants ; large cities are few ; and the 
specialties of medicine not highly developed except in one 
or two medical centers. The state consists of 9,565 square 
miles of mountainous country and many of the less traveled 
roads are difficult to negotiate, even in the best of weather. 

Knowing the situation, an anonymous friend of the state 
placed at the disposal of the State Board of Health a gener- 
ous sum to be used in the study of the prevention and care 
of poliomyelitis. It was decided to attempt to furnish care 
to as many of these children as possible, and in December, 
1914, 1 was asked by the State Board of Health to go to Ver- 

275 



276 INFANTILE PARALYSIS IN VERMONT 

mont and undertake the work. On making a survey of the 
situation, it was found to be impossible at this season, or in 
fact at any other time, to see the cases individually in their 
homes, and it was decided to hold clinics at certain centers 
in the infected regions to which the cases might be brought 
for examination and direction as to treatment. 

Poliomyelitis is a condition which is attended by high 
mortality in the acute disease. When the acute stage is over, 
spontaneous improvement immediately begins and continues 
for a time, after which disabling deformities are likely to 
set in. As is well known, in a certain number of instances 
these deformities cause such disability that the patient be- 
comes a dependent or in any event fails to obtain the degree 
of recovery which it is right to expect would be possible 
under favorable conditions of treatment. 

After considering the subject, the best solution seemed to 
be to examine the cases in consultation with the family doc- 
tor, who was invited to come to the clinic, and to advise him 
as to the measures to be followed and to instruct the family 
in carrying out such exercises and manipulations as seemed 
advisable. 

The first series of free, public clinics for poliomyelitis in 
this country were conducted in this way in December, 1914, 
and January, 1915, in the state of Vermont. I was aided in 
this work by my assistant in private practice, Miss Wilhel- 
mine G. Wright. The most important centers were visited, 
— Burlington, Montpelier, Barton, Rutland, and St. Albans, 
5 in all. Two hundred and twelve cases were examined at 
this time and physicians and parents were advised as to the 
care and treatment to be given each patient. There was no 
provision made for follow-up work after the patient was 
seen at the clinic, a matter which later proved a serious 
defect in the work, but at the outset the whole proposition 
was so very uncertain that it seemed best to progress slowly 
and see what measures were possible. 



HISTORY OF AFTER-CARE OF POLIOMYELITIS 277 

During the following summer, — in July, 1915, — clinics 
were again held in the same places and we had the advan- 
tage of the presence of Dr. E. G. Martin, at that time 
Assistant Professor of Physiology in the Harvard Medical 
School, now Professor of Physiology in Leland Stanford 
University. Dr. Martin was interested with me in evolving 
a quantitative method of estimating muscle strength which 
we used at this time and which has been very extensively 
used since. Up to this time the strength of the muscles was 
estimated by hand and the condition was much as if one 
were studying typhoid without the advantage of a thermom- 
eter. The method proved to be practical and much of the 
information derived from the study of the Vermont cases 
was due to the more accurate method afforded by the so- 
called "spring balance" test. 1 

Miss Wright and also Miss Janet B. Merrill of the Chil- 
dren's Hospital, Boston, came to assist at the clinics. One 
hundred and twenty-two examinations were made at this 
time. The patients who had followed the treatment pre- 
scribed at the previous clinic showed marked improvement, 
nevertheless it was realized that even better results could 
be obtained if the advice to parents could be supplemented 
by the supervision of a trained field worker who could visit 
the homes and follow up the treatment prescribed. Miss 
Merrill was the first to hold this position and spent two 
months in Vermont during the summer of 1915 after the 
clinics, making her headquarters in Burlington. 

By December, 1915, enough new cases had been seen at 
the summer clinics or had applied for treatment to bring 
the number up to 243 for the year 1915. On this number of 
cases 334 clinical examinations were made either by the 
surgeon or his assistants. 

The difficulty of getting about the country with the rather 
inadequate train service restricted the work to the care of 



described in detail on page 252. 



278 INFANTILE PARALYSIS IN VERMONT 

those patients who lived in or near the larger centers. Miss 
Merrill, working in cooperation with the family physician, 
gave personal supervision to the muscle training of these 
patients and taught some member of each family to give the 
exercises, massage, etc., in her absence. The value of this 
work was demonstrated beyond question by the results of 
the muscle test given to each patient by Dr. Martin at the 
end of Miss Merrill's stay. These tests showed that the 
improvement in each case was in exact ratio to the amount 
of training and supervision given. 

Incidental to the work, some cases which proved not to be 
poliomyelitis were brought for examination and have been 
included in these numbers. 

Miss Merrill took up the field work again in the summer 
of 1916. This time the use of an automobile enabled her to 
cover a larger area and to save much valuable time. As- 
sisted by Miss Merrill and Miss Miriam T. Sweeney, I held 
a series of clinics in July. For a few weeks after the clinics 
Miss Sweeney remained in Vermont to assist in the field 
work by taking charge of the muscle training of the patients 
in Burlington. No work was done by the Af ter-Care Depart- 
ment during the autumn, but in the winter Miss Merrill re- 
turned to Vermont and held bi-weekly clinics in the larger 
centers. This made it possible for her to give careful super- 
vision to such cases as could be brought to her, and to see 
each patient at least once in two months. During 1916, 42 
patients who had not been examined previously came to the 
clinics and were taken under treatment. 

In 1917 a severe epidemic occurred in the Montpelier dis- 
trict and, because of the additional demands, it was advis- 
able to have two field workers. Miss Merrill was unable to 
continue with the work and resigned after starting Miss 
Helen King and Miss Rebecca Selfridge in the field. Miss 
Self ridge concentrated on the new cases in and about Mont- 
pelier while Miss King took charge of the work in the rest 



HISTORY OF AFTER-CARE OF POLIOMYELITIS 279 

of the state. Clinics were held by me in August with the 
assistance of the field workers, and 186 examinations were 
made. During this year 119 new patients were admitted to 
treatment, 79 of which were cases of recent onset. 

Prior to 1917 the work was of necessity restricted to the 
larger centers and the territory immediately adjacent, and 
it was limited to those patients who had applied to the clin- 
ics for treatment. During 1917 the first effort was made to 
investigate the cases near each center which had not re- 
ported to the clinics for examination. 

In 1918 the war depleted the staff to such an extent that 
the work of the department was practically brought to a 
standstill. Miss King resigned to take up reconstruction 
work in France and I was in the army, so that no clinics 
could be held. Only 14 new patients were admitted to treat- 
ment during the whole year. Miss Self ridge bore the entire 
burden of the work alone until the end of the summer when 
she resigned. From that time until the following spring of 
1919, the department ceased functioning and the patients 
were without supervision. 

Meanwhile, the Board of Health was besieged with re- 
quests for help,- — existing deformities were increasing and 
new ones were developing; braces had been broken or out- 
grown ; new cases needed examination and advice, — so that 
when the department resumed its activities again in May, 
1919, in charge of Miss Bertha E. Weisbrod, the situation 
was acute. An accumulation of work in arrears required 
attention in addition to the need for meeting each day's new 
demands; a certain discouragement engendered in some of 
the patients by the interruption of the work and the uncer- 
tainty of its continuance must be met and overcome ; 500 or 
more cases scattered over the northern part of the state 
must be followed up, — these were some of the conditions 
which faced the new regime. An immediate effort was made 
to get in touch with as many patients as possible and to per- 



280 INFANTILE PARALYSIS IN VERMONT 

suade them to attend the clinics, with the gratifying result 
that 418 reported for examination during the year. This was 
more than had ever been examined in any one previous year, 
and more than double the number of examinations in any of 
the three preceding years. During 1914-1915, 334 clinical 
examinations had been made, but this was the year of the 
epidemic when excitement was rife and the parents seized 
every opportunity for help. In 1916-17-18, there were fewer 
patients at the clinics for two reasons : first, many had been 
discharged as cured ; second, a natural reaction had set in, — 
the parents had grown used to the situation and were in- 
clined to let things drift. The increased number in 1919 
shows how fruitful was the effort to counteract this discour- 
agement and stimulate interest. 

The department inaugurated a new policy with regard to 
the follow-up work during 1919. Before this time visits to 
the homes of the patients had been restricted to the summer 
months and while clinics were held by the supervising nurse 
during the winter, only such patients as could be brought to 
them could be kept under constant supervision. In 1919, the 
department not only held winter clinics but also continued 
to make home visits during the entire year. This is still the 
policy of the department and the follow-up work in the 
homes is carried on without interruption even through the 
most severe Vermont winter. 

In 1919 the first clinics since August, 1917, were held by 
me in July, and a sixth center, St. Johnsbury, was added at 
this time. Three additional clinics were conducted by Miss 
Weisbrod during the year, and the examinations showed 
conclusively that the previous work had been well worth 
doing. The patients who had followed the prescribed treat- 
ment of rest, massage, and carefully graded muscular exer- 
cises had made great gains. At this time there were com- 
paratively few cases of recent onset, and a number of the old 
cases had reached the stage where operations were advis- 



HISTORY OF AFTER-CARE OF POLIOMYELITIS 281 

able and braces more essential than continued muscle train- 
ing. 

These two outstanding features offered new problems to 
be solved. Hitherto, braces and other apparatus had been 
made at the Appliance Shop of the Children's Hospital in 
Boston. This shop was overcrowded with work and often it 
was necessary to wait undesirably long before orders could 
be filled. Therefore, it was decided to try to make the appli- 
ances for the Vermont cases in that state. Mr. Frank A. 
Dresser, an instructor in the Engineering Department of 
the University of Vermont, an expert in mechanics, became 
interested and learned to make the various types of braces 
needed. The results of the experiment were so satisfactory 
that the appliance shop became a permanent institution and 
since it started the braces have been delivered more prompt- 
ly and have fitted most satisfactorily. Mr. Dresser has made 
various improvements in the braces which have added to 
their efficiency and to the comfort of the patients. At the 
present time the department is trying one of the newer 
metals, duralumin, which is two-thirds lighter than steel 
and promises to be of great value for braces in this work, 
since the wearing qualities are proving satisfactory. 

Meanwhile, a new problem had arisen in the matter of 
cases requiring operation. At the end of the second year and 
sometimes earlier, deformities begin to arise in poliomyeli- 
tis, such as drawing up of the knee or hip, or similar condi- 
tions which, although preventable, occur in a certain num- 
ber of cases. To allow these deformities to go uncorrected is 
to bid for disability, and the relief of them in the majority 
of cases is a simple matter if operated on under the best 
conditions. Up to 1919 a few urgent cases had been operated 
on either in hospitals in Vermont or had been sent down to 
the Children's Hospital in Boston but the problem was be- 
coming increasingly troublesome. In 1919 it became evident 
that some definite plan would have to be adopted. The mat- 



282 INFANTILE PARALYSIS IN VERMONT 

ter presented certain difficulties, however, because many of 
the parents were opposed to having operations performed, 
and a great deal of time had to be spent in educational work 
before the necessary permission could be secured. When this 
was finally achieved, it was found that the hospital accom- 
modations hitherto available were inadequate for the in- 
creased number of operative cases. Some of the patients had 
been operated on at local institutions by local physicians, 
several special cases were taken to the Hospital for the 
Ruptured and Crippled in New York to be under the care of 
Dr. Armitage Whitman, the majority of those under 12 
years of age were operated on at the Children's Hospital in 
Boston by my colleague, Dr. F. R. Ober, or myself ; but all 
of these hospitals had long waiting lists and additional ac- 
commodations were necessary. Moreover, in order to secure 
the best results with the patients from the rural districts 
it was important to keep them close at hand until the plaster 
casts had been removed and all apparatus had been fitted. 
The remoteness of their homes made it impossible to give 
them proper supervision in any other way. Therefore it 
was decided to secure hospital space in Vermont where Dr. 
Ober could operate and where the post-operative care could 
be continued as long as necessary. 

As a result of this decision, in the winter of 1919 two 
wards of six beds each were rented from the Proctor Hos- 
pital in Proctor, Vermont. Miss Madeline Gibbs, a graduate 
of the Children's Hospital and especially trained in ortho- 
pedic work, was placed in charge and the department pro- 
cured all the necessary orthopedic apparatus. 

Twelve patients were taken to the hospital on December 
5, and on December 7 Dr. Ober and his staff arrived from 
Boston. Dr. Ober operated for two days and stayed one 
more day to observe the condition of the patients. After 
that he returned for four week-ends to perform subsequent 
operations and to change plaster casts. By the middle of 



HISTORY OF AFTER-CARE OF POLIOMYELITIS 283 

March the last patients were discharged. The venture was 
successful in every respect and all the patients showed great 
improvement. The change in these children, together with 
the fact that they had been so well cared for and actually 
happy while in the hospital, did much to mitigate the dread 
of operations and to remove the prejudice against hospitals 
in the parts of the state from which these little patients had 
come. The highly satisfactory results in these operative 
cases were due in part to the fact that the patients were 
given the best of post-operative care in their homes after 
their discharge from the hospital. Each case was followed 
up at home by the field worker and kept under careful 
supervision until everything possible had been done to in- 
sure a complete recovery. This plan of providing proper 
post-operative care in the homes, initiated in 1919, has be- 
come a permanent part of the regular work of the depart- 
ment. 

In 1919, 36 patients were operated on, — 12 at the Proctor 
Hospital and the remaining cases either in hospitals in Ver- 
mont, the Hospital for the Ruptured and Crippled in New 
York, or the Children's Hospital in Boston. 

Throughout 1919 Miss Weisbrod carried on the field work 
entirely alone, but in the autumn a secretary, Miss G. F. 
MacBride, was provided to assist her in the office and with 
the records. During the year, 270 cases were under super- 
vision, 69 new patients applied for treatment, there were 
418 examinations at clinics, 330 home visits were made, and 
87 pieces of apparatus were fitted. 

On May 1, 1920, an assistant field worker was added to 
the staff, the position being filled by Miss Marjorie Hickok. 
It will be remembered that prior to 1919, the field work 
had been restricted to the cases comparatively near the 
clinic centers and that in 1919 attention was directed to 
following up all the cases in and about, those centers and 
getting them to report for examination. In 1920, a special 



284 INFANTILE PARALYSIS IN VERMONT 

effort was made to locate all the cases on record in every 
part of the state, in addition to carrying on the regular 
work. It was found that 250 patients had not been seen for 
two years or more. All but 24 of these were traced. Even 
the most remote localities were visited and the condition of 
each patient, the treatment prescribed, care in following it, 
extent to which disability interfered with education and 
self-support, and the approximate amount of improvement, 
were noted on each record in order that a statistical study 
might be made, showing what the work had accomplished. 
The preliminary work was completed by September 1st, at 
which time Miss Catherine D. Jones, of the School of Public 
Health of Harvard University and Massachusetts Institute 
of Technology, came to Burlington to compile the figures. 
This study of the records was continued through 1921, and 
the results are presented in the statistics given at the end 
of this article. 

During the summer of 1920, the usual clinics were held, 
but this time in charge of Dr. Ober, as I was in Europe, 
and a new clinic center was added at Barre. The first of 
November, the assistant field worker, Miss Hickok, was 
obliged to resign because of ill health and Miss Weisbrod 
carried on the work alone during the rest of that year. After 
the summer series of clinics, two subsidiary ones were held 
by Miss Weisbrod with the addition of still another center, 
Windsor, making 8 clinic centers in all. At the 1920 clinics 
not only were the usual examinations given and treatment 
prescribed but all apparatus was adjusted and plaster casts 
were made for jackets. Sixty-eight new patients applied 
for treatment during the year. 

In view of the fact that the age limit for admission to the 
Children's Hospital in Boston was 12 years and because of 
the increasing number of patients in need of operation, it 
seemed advisable to secure accommodations in some other 
hospital where Dr. Ober might operate and where the de- 



HISTORY OF AFTER-CARE OF POLIOMYELITIS 285 

partment could be in complete charge of the post-operative 
care. Kimball Cottage, a hospital building connected with 
the New England Hospital for Women and Children, in 
Boston, was finally rented. The New England Hospital fur- 
nished heat, light, food, and laundry. In all other respects 
the organization was wholly independent. 

This hospital was opened on November 13, 1920, with 36 
patients from 3 to 26 years of age. These patients were all 
taken to Boston on the same day by railroad. The parents 
took the children to the nearest railroad station where they 
were met by workers who cared for them during the jour- 
ney. The Volunteer Red Cross Motor Service carried them 
from the North Station to the hospital. 

Forty-eight patients in all were operated on at Kimball 
Cottage. Of these, 35 were treated for deformities caused 
by poliomyelitis and 13 for deformities arising from other 
causes. Twenty-two had tonsils and adenoids removed by 
Dr. Calvin B. Faunce. Dr. George Derby examined the 
eyes of all the patients and fitted 6 with glasses. The teeth 
of all the patients were cleaned and all necessary filling and 
extracting was done by Dr. Johnson. 

In addition to the excellent physical care given to the 
children, everything possible was done to keep them con- 
tented and happy. Children of school age were supplied 
with teachers so that all of them were able to keep up with 
their classes. Through the kindness of friends of Vermont 
in Boston, the patients were frequently taken on automobile 
rides or in the electric cars, which proved even more of a 
treat to some of these youngsters from the rural districts 
who had never even seen a street car before. Battleships, 
submarines, all these things were new to them, and conva- 
lescence instead of being just a number of dreary days to be 
dragged through became a thrilling adventure from begin- 
ning to end. Their escorts declared that it was more fun to 
take these keen, interested patients around the city than 



286 INFANTILE PARALYSIS IN VERMONT 

anything else they could do, and the children themselves de- 
rived as much mental stimulus as physical benefit from their 
stay in Boston. 

Each year from the beginning the work had presented its 
own problems and in time a satisfactory solution for each 
had been found. Gradually the scope of the work had 
broadened and the area covered had increased until in 1920 
practically the whole of the state was under supervision, 
the surgical care was as good as we could make it, hospital 
and post-operative care had reached a high point of effi- 
ciency, but a serious problem still presented itself for solu- 
tion. 

The home surroundings of some of the patients were such 
that it was impossible to secure the best results if the chil- 
dren must be sent back from the hospital to face such living 
conditions. Sometimes it was merely a question of remote- 
ness, the child could not be visited often enough to insure 
proper care; again, the financial status of the parents or the 
demands of a large family made it impossible for them to 
give the necessary treatment at home ; and what was very 
important, in many cases a combination of these circum- 
stances made it impossible for the children to attend school 
at all. During this year, one of the dreams of those inter- 
ested in the after-care work was realized and provision was 
made for just these children. Through the generosity of a 
public spirited citizen of Vermont, Ormsbee House, a school 
and home for crippled children, was opened in Proctor, Ver- 
mont, on January 5, 1921. This school can take care of 18 
children between the ages of 6 and 12, and although it can- 
not meet the entire need because its size does not enable 
children over 12 to be kept, it is ideal for those to whom it 
is available. The school is free to those who cannot afford 
to pay, so that the children who need it most may enjoy its 
privileges. 



HISTORY OF AFTER-CARE OF POLIOMYELITIS 287 

The house was built especially for these children. In addi- 
tion to a staircase, an incline to the second floor is provided 
so that children with long braces and crutches may ascend 
easily. There is a well-equipped gymnasium where the exer- 
cises and muscle training are given. The large, sunny play- 
room has a sun-parlor at one end, an open fireplace, a piano, 
a victrola, couches, well-filled book shelves, and toys to de- 
light the heart of any child. Just outside is a garden of their 
own and even an automobile is at hand for their use. Every- 
where there are evidences of thought for the convenience 
and happiness of the pupils. Every bit of equipment is so 
carefully adjusted to their special needs as to render the 
children as independent of aid and as much like normal 
children as possible. A real home atmosphere pervades the 
school and there is nothing remotely suggestive of institu- 
tional life about it. A nurse, Miss Ina Allen, who is admira- 
bly adapted to the work, is in charge and under her careful 
supervision they are kept busy and happy from morning 
until night. Lessons are given to them in shorter periods 
than in the schools for normal children and in addition to 
the regular school work, cooking, sewing, and handicraft 
are taught, as well as music for those of special ability. 

Of the children at Ormsbee House, five of the eighteen 
could only crawl when they originally came to the clinics 
and now they walk amazingly well even though braces and 
crutches are still necessary. All of the children show great 
improvement from month to month, physically, mentally, 
and morally, and they are happier in every way than in 
their own homes, for here they not only have the best of care 
and understanding but are spared the continual struggle to 
keep up with physically normal children which would be 
inevitable elsewhere. 

During 1920, 68 new cases applied for treatment, 482 
home visits were made, 162 pieces of apparatus were fitted, 
131 braces were adjusted, orthopedic corrections were made 



288 INFANTILE PARALYSIS IN VERMONT 

to shoes in 110 cases, exercises were taught to 144 patients, 
and 72* patients were operated on. 

In the spring of 1921 the position of assistant field 
worker, which had been vacant since Miss Hickok's resigna- 
tion in November, 1920, was filled by Miss Marguerite Belt 
of the Children's Hospital in Boston. In October Miss Belt 
was transferred to Kimball Cottage while Miss Margery C. 
Kerr became assistant field worker in her place. 

Clinics were held in July with the addition of a ninth 
center at Proctor. I was in charge of the clinics at Rutland, 
Proctor, Burlington, and St. Albans, and Dr. Ober in charge 
at Barton, Montpelier, St. Johnsbury, Barre, and Windsor. 
Miss Weisbrod conducted subsidiary clinics in October and 
May. 

In 1921, 463 patients were under supervision, 79 new 
cases applied for treatment, 568 home visits were made, 
172 pieces of apparatus were applied, 114 pieces of appara- 
tus were adjusted or repaired, 109 orthopedic corrections 
to shoes were made, and 71* cases were operated on. 

The method of caring for the operative cases in 1920 had 
shown such excellent results that Kimball Cottage was 
again rented from the New England Hospital and was 
opened on December 1, 1921, with 34 patients. The Red 
Cross Motor Corps again helped to transfer the patients 
from station to hospital and the societies of the "Daughters 
of Vermont" and the "Sons of Vermont" did much to make 
the children happy during their stay in Boston. Owing to 
the prevalence of contagious diseases in Boston, it was 
deemed inadvisable to have the teachers come into the hos- 
pital daily to keep up the school work as had been done be- 
fore. In spite of every precaution, however, the department 
sustained its first loss of life, for one of the children con- 
tracted scarlet fever three days after operation and died 
from an embolus. Forty-one cases in all were operated upon 



*Including operations performed on some non infantile paralysis cases. 



HISTORY OF AFTER-CARE OF POLIOMYELITIS 289 

at Kimball Cottage, the remaining 30 cases in Vermont, 
New York, or Boston, and the results of the year's work 
were wholly satisfactory. 

In 1921, an addition to the work was made which seems 
to have been as important as any previous extension of 
activities. A careful study of the patients under the super- 
vision of the department showed that while the greater 
number of adults were self-supporting, nevertheless there 
were a few who, because of their disability and isolation 
from suitable work, were unable to contribute materially to 
their own support. In September, 1921, a department of vo- 
cational training was started under the supervision of Miss 
Margaret B. Ives. This was done because there were two 
classes of cases who were found to be in need of such help. 
The patients who had been in the hospital and by operations 
and other treatment had been improved in their range of 
activities, on their return home became restless and un- 
happy because of their isolation and disability and it was 
obvious that if the best physical and mental results were to 
be obtained from these cases, some occupation must be pro- 
vided. In a second class where the patient was isolated by 
his disability or perhaps lived in the mountains away from 
much contact with people, it became evident that some out- 
side interest would be of great help in stimulating ambition, 
especially if it offered any hope of making the patient fi- 
nancially independent. This latter aspect, — the fact that a 
man practically helpless could earn a certain amount of 
money, — has proved most stimulating psychologically and 
physically. The patients are visited by their teacher at the 
outset who shows them the various possibilities in the way 
of making articles and instructs them in the one that they 
select. She visits them at frequent intervals to see that the 
standard of work is kept up and stimulates them to further 
efforts in improving their work or becoming independent in 
the matter of designing, etc. This department finds suitable 



290 INFANTILE PARALYSIS IN VERMONT 

work for the patient, gives instruction free, furnishes raw 
material to be paid for when the products are sold, and finds 
a market for the articles made. The handicrafts taught are 
weaving, rug-making, toy-making, basket-making, and vari- 
ous types of needlework. 

The results of this branch of the work have been most 
satisfactory, and the interest and appreciation shown have 
proved it worth the undertaking. Aside from the economic 
value of enabling these remade individuals to discharge 
their debt to the community, the moral effect of this work on 
the patients themselves can scarcely be over-estimated, for 
through it they have acquired independence and self-respect 
and have become useful citizens. 

During 1922 no changes of any significance were made 
in the work of the department. Dr. Ober and I held a series 
of clinics in nine centers in August, and Miss Weisbrod 
held clinics in the same centers in May and October. At the 
clinics in 1922 very few operative cases presented them- 
selves, a situation in great contrast to the conditions of the 
earlier clinics. It would seem to be that not only have the 
operative cases been taken care of, but the persistent fol- 
lowing up of the cases and holding them to treatment have 
resulted in preventing, in a large measure, the severe de- 
formities requiring operative treatment. 

STATISTICS 

Throughout these statistics cases of infantile paralysis, 
in which the onset of the disease occurred at least a year 
previous to the date of first examination by the Department 
for the After-Care of Poliomyelitis, are called "old cases." 
Cases which were examined within a year of the date of on- 
set of the disease are called "recent cases." 

The work began at the termination of a large epidemic 
throughout the state. At the clinics of the first year 243 
cases were admitted, the largest number for any single year. 



HISTORY OF AFTER-CARE OF POLIOMYELITIS 291 

Two-thirds of these cases were poliomyelitis cases of the re- 
cent epidemic, but there were also 70 cases of long standing 
paralysis, showing the need of such work without an epi- 
demic. 

In the next year, 1916, there were only 42 admissions. 
Over half of these — 24 cases — were recent cases, left-overs 
from the 1914 epidemic and imported cases from the larger 
1916 epidemic in other states. 

In 1917 the number of cases rose again, the total being 
119. The large number of new cases — 79 — came almost en- 
tirely from the Montpelier district where there was a very 
severe but very local epidemic. 

In 1918 the work was practically at a standstill, and only 
14 new cases were recorded. 

During the years 1919 and 1920 there was an entirely new 
distribution of cases, and one which might be regarded as 
the normal for an established work in years when there 
were no epidemics. In each year there was a small number 
of new cases, and a considerable number of old cases largely 
from the epidemics of 1914 and 1917. 

TABLE 1 

Number of Poliomyelitis Cases Admitted to Clinics 

1914-1921 



Year of First 


Old Cases 


Recent Cases 


Total 


Attendance 








1914 and 1915 


70 


173 


243 


1916 


18 


24 


42 


1917 


40 


79 


119 


1918 


8 


6 


14 


1919 


54 


15 


69 


1920 


62 


6 


68 


1921 


38 


41 


79 



In 1921 the incidence of the disease again increased, and 
is shown in the increase of recent cases admitted to the 
clinics. 



292 INFANTILE PARALYSIS IN VERMONT 

The total number of cases of poliomyelitis admitted to the 
clinics to January 1, 1922, was 634. Of this number 54 per 
cent, or 344 cases, were cases which the department was 
given the opportunity to treat within one year of the onset 
of the disease. Forty-six per cent, or 290, were cases where 
the paralysis had been present for a year or more before 
the treatment was started. 

TABLE 2 

Year of Onset of all Poliomyelitis Cases Seen by 
the Department to January 1, 1922 



Year of Onset Number of Cases 

1840 f. 1 

1880-1889 3 

1890-1899 10 

1900-1904 13 

1905-1909 26 

1910 30 

1911 29 

1912 10 

1913 18 

1914 207 

1915 27 

1916 60 

1917 104 

1918 10 

1919 18 

1920 6 

1921 35 

Date of onset not known 27 

Total number of cases 634 



TABLE 3 

Summary of Inactive Cases of Poliomyelitis 
to January, 1921 



No treatment prescribed 
at first clinic attended* 

Refused treatment 

Private cases 

Moved from state 

Preferred osteopathic or 
chiropractic treatment 

Died 



Old Cases 


Recent Cases 


Total Cases 


4 


35 


39 


16 


22 


38 


1 





1 


20 


27 


47 


4 


4 


8 


5 


11 


16 



HISTORY OF AFTER-CARE OF POLIOMYELITIS 293 

Cannot be located 9 15 24 

Cases dropped 5 12 17 

Referred to New York 

Commission 1 5 6 

No further treatment 

needed 14 34 48 

All cases 79 165 244 

♦Includes abortive cases, cases showing no paralysis, and cases 
which were seen but once by the department. 

In 1921, when this study was made, 244 cases of polio- 
myelitis which had previously been seen at clinics were no 
longer under active treatment. Of this number, 39 had not 
needed any treatment when first seen at the clinics, 35 of 
these being recent cases not showing any paralysis at the 
first examination. Thirty-eight cases had continually re- 
fused treatment, but the Department still carried many of 
these cases on its inactive files, hoping to help them later. 
Sixteen of the number had died, and 6 had been referred 
to the New York Commission. Seventeen cases had been 
dropped because of family conditions and lack of coopera- 
tion. No further treatment was needed by 48 cases, prac- 
tically all of whom had been considered "normal" or "prac- 
tically normal" by the attending surgeons. 

Table 4 was compiled in 1921, and is a consideration of 
380 cases. They include recent and old infantile paralysis 
cases which were admitted to clinics before January, 1920, 
and treated regularly by the Department. 

Of the 380 cases, 155 were old and 225 were recent cases. 
Of the old cases 85, or 55 per cent, were considered to have 
followed treatment regularly during their supervision by 
the Department. That means that they did the prescribed 
exercises regularly, wore the apparatus advised, and under- 
went operations without long delay. Of these patients only 
two failed to improve, and at the time this was written 
these two were in approximately the same condition as they 
were at the time of admission. Thirty-nine per cent fol- 



294 



INFANTILE PARALYSIS IN VERMONT 





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HISTORY OF AFTER-CARE OF POLIOMYELITIS 295 

lowed treatment irregularly; that is, they did their exer- 
cises only fitfully, wore their braces only part of the time, or 
delayed in having the advised operations. Nevertheless, 34, 
or more than half of the cases improved, and only one case 
became worse. The majority of the cases who did not fol- 
low treatment at all were cases which continually refused 
operation. In none of these cases was there any improve- 
ment, but only three of the ten actually lost ground. 

Of the 225 new cases, 133, or 60 per cent followed treat- 
ment regularly, and of this number all except 2 gained. The 
only case which lost was a very light case which followed 
treatment regularly for several years, missed one year of 
clinics (1918), and in 1920 was found to have developed 
a slight cavus and claw foot, probably from overuse. The 
cases that followed treatment irregularly numbered 80, or 
36 per cent; but more than half of these improved, 5 were 
the same in 1921, and 4 had lost. 

In comparing the improvement of the old and recent 
cases, it will be seen, that 81 per cent of the new cases gained, 
as contrasted with a gain in 76 per cent of the old cases. 
That the gain is greater in the new cases is due to the fact 
that the natural tendency of the disease is to improve, and 
it is well known to be more amenable in the first two years 
than at any other time. One remarkable thing shown by the 
figures is the large number of old cases which improved, for, 
while in some of the cases the duration of the paralysis had 
been short, in many instances it had been present for from 
10 to 20 years. To a large degree, of course, this improve- 
ment was due to the performance of successful operations, 
but the figures also show that another class of case existed 
which was not operated on and yet improved late in the 
history. The improvement in this latter group was un- 
doubtedly attributable to the fact that these cases had not 
had proper treatment since the onset of the disease and 
many had been practically neglected. The point should be 



296 INFANTILE PARALYSIS IN VERMONT 

stressed, however, that improvement is possible in cases of 
many years' duration. 

TABLE 5 

Number and Percentage of Cases of Poliomyelitis 

Having Undergone, Having under Consideration, 

or Having Refused Operations Advised by 

the Department 

Number Per cent 

Cases operated on at the advice 
of the Department: 

1914-1919 62 

1920 49 

1921 44 

1922 (to July) 7 

Cases in the hospital 

Cases considering operations, the performance 
of which has been advised 

Cases refusing to have operations advised .... 

Cases having died or left the state before opera- 
tion could be performed 

Total number of operative cases 250 100 

Percentage of all cases of poliomyelitis treated 

at the clinics which were operative cases . . 47.4% 

From these figures it will be seen that of the cases for 
which operation was deemed necessary, 22 per cent refused 
operative permission, 7 per cent were considering having 
the operations but had not made up their minds at the time 
these figures were compiled, and 1 per cent had died or left 
the state before operation could be performed. 

Whether or not this situation would be found to exist in 
other localities cannot be decided, but in Vermont the ex- 
perience has been that as the communities became better 
educated in the matter of operations and hospital treatment 
the percentage of cases willing and glad to go to a hospital 
and be operated on constantly increased. It was found in 
Vermont that no influence in the community was as power- 
ful in diminishing the opposition to operative treatment as 
the return of successfully operated children to their homes, 



162 
13 


65 
5 


17 
55 


7 
22 


3 


1 



HISTORY OF AFTER-CARE OF POLIOMYELITIS 297 

and in localities where this occurred the opposition prac- 
tically disappeared. 

TABLE 6 

Number and Percentage of Old and Recent Cases of Poliomye- 
litis for which Exercises Were and Were not Prescribed 

Old Cases Recent Cases Total Cases 
No. % No. % No. % 

All cases admitted before 
Jan., 1920, and actively 
treated by the depart- 
ment 155 100 225 100 380 100 

Cases for which exer- 
cises were not pre- 
scribed 51 33 31 14 82 22 

Cases for which e x e r- 



cises were 


prescribed . 


104 


67 


194 86 


298 


78 


Number and Percentage which Followed Exercises 
Regularly, Irregularly, or Not at All 




V 


Old Cases 
No. % 


Recent Cases 

No. % 


Total Cases 

No. % 



All cases for which exer- 
cises were prescribed . 104 100 194 100 298 100 

Cases following exercises 

regularly 64 62 121 62 185 62 

Cases following exercises 

irregularly 23 22 56 29 79 27 

Cases not following exer- 
cises at all 17 16 17 9 34 11 



This table was compiled in January, 1921, and includes 
only cases admitted and actively treated by the Department 
previous to January 1, 1920. With regard to the coopera- 
tion to be obtained from the patients, from the best infor- 
mation at our disposal, Table 6 shows what really happens 
with regard to following out exercises at home. 

In many cases the parents considered that the patients 
did the exercises regularly, when that would hardly have 
been the opinion of the supervisor. Some cases did exercises 
very regularly under supervision, but were very irregular 
later when there was no supervision. Cases which did not 



298 INFANTILE PARALYSIS IN VERMONT 

do their exercises well before operation were very careful 
about them after operation. It was also noticed that, in gen- 
eral, parents who gave exercises faithfully admitted their 
usefulness, while those who became discouraged after a cou- 
ple of weeks felt that the exercises were "of no earthly use," 
and often expressed the opinion that the patient got "all the 
exercise he needed playing outdoors." Ninety-two per cent 
of the parents or adult patients who gave exercises regu- 
larly believed that they aided. 

TABLE 7 

Walking Ability of Cases of Poliomyelitis 
before and after treatment by the department 

Old Cases Recent Cases All Cases 

Number of cases unable to 
walk at time of admis- 
sion ,36 52 88 

Able to walk in 1922 27 46 73 

Unable to walk in 1922* . . 7 4 11 

Number of cases having 

died by 1922 2 2 4 

The reasons for inability to walk in the 11 cases were as follows: 

Continually refused necessary operations 6 

Practically no power available in legs or arms 3 

No ambition to attempt walking 1 

1921 case not yet allowed to attempt to walk 1 



Total 11 

The above figures show that of the 634 cases of infantile 
paralysis admitted to the care of the Department previous 
to January, 1922, 88, or 14 per cent were unable to walk at 
the time of admission. In July, 1922, 11 of the 634 cases, or 
1.7 per cent were still unable to walk. Of this number, 7 
were unable to walk because of their own lack of coopera- 
tion. One case had not been allowed to attempt walking. Of 
the 634 cases this leaves only 3 which, under favorable con- 
ditions of treatment and cooperation on the part of the pa- 
tient, were still unable to walk in 1922, — less than y% of 1 
per cent. 



HISTORY OF AFTER-CARE OF POLIOMYELITIS 299 

TABLE 8 

Occupations op all Infantile Paralysis Cases Admitted 

before January, 1920, and Actively Treated 

by the Department* 

Children 262 

Go to school regularly 220 

Go to school for crippled children 17 

Go to school irregularly 4 

Do not go to school 1 10 

Too young to go to school 11 

Adults 80 

Earn their own living 69 

Earn part of their own living 2 6 

Do not earn anything 3 5 

Dead 14 

Occupation not known 24 



Total cases 380 

*This table was compiled in January, 1922. 

includes 4 children mentally deficient, 1 child deaf and taught at 
home, 2 children living too far from school and taught at home, 1 
child to go to school for crippled children, and 2 children unable to 
walk because parents refuse to allow necessary operations. 

2 Working under direction of Miss Ives, the Vocational Supervisor, 
and will eventually be self supporting. 

includes 2 patients unable to walk because they refuse necessary 
operations, 1 patient too severely paralyzed, 1 patient refuses to co- 
operate with Vocational Supervisor, 1 patient who does a small 
amount of house work. 

The two preceding tables deal with the present condition, 
from an economic point of view, of all cases of infantile 
paralysis admitted to the care of the department previous 
to January, 1920. The figures show that it is exceptional 
for a child to be unable to go to school regularly on account 
of his paralysis, and that the majority of the adults are able 
to earn their own living. 

Of the 80 adults whose occupations are known, there are 
only 11 who are not entirely self supporting. An analysis 
of those who are self supporting shows that they did not as 
a rule seek sedentary occupation, but indulged in all sorts of 
activities. It should also be noticed that nearly 20 per cent 



300 



INFANTILE PARALYSIS IN VERMONT 



of the group now engaged in active work were unable to 
walk when first seen. 

TABLE 9 

Occupations of Infantile Paralysis Cases 

Earning Their Own Living 

1922 



Occupations 


Number earning 


Number which were 






living 


unable to walk at 
admission 


Farming 




17 


2 


Housework 




11 


2 


Office work 




11 


3 


Garage work 




4 


2 


Salesmanship 




2 


1 


Lumbering 




2 





Factory labor 




3 


2 


Telephone operating 




2 


1 


Shoe repairing 




1 





Sewing 




1 





Teaching 




2 





Studying and working 


• way 






through college 




2 





Photography 




1 





Gardening 




1 





Machine work 




1 





Running saw mill 




1 


1 


Working, but exact 


occu- 






pation not known 




7 





Total 




69 


14 



SUMMARY 

The plan for the after-care of poliomyelitis in Vermont 
has thus gradually expanded, until, from being in 1914 just 
a series of public clinics it is now a definitely organized de- 
partment of the State Board of Health, functioning the year 
around and undertaking the supervision of every case of 
poliomyelitis in the state from the time the quarantine is 
lifted until the best possible recovery has been made. 

The preceding statistics were compiled from the records, 
and from them it seems evident that the number of disabili- 
ties from poliomyelitis has been very greatly diminished; 
that many individuals are now wage-earners who otherwise 



HISTORY OF AFTER-CARE OF POLIOMYELITIS 301 

would not have been; and that, on the whole, the patients 
have been appreciative and cooperative. I do not believe 
that anywhere there will be found a group of cases of polio- 
myelitis where the end results are more satisfactory than 
in the group of cases under consideration. The scheme, 
originally beginning in such a small way, has itself indicated 
the lines along which its development should take place and 
each addition has been justified. 

At present, some years after a serious epidemic, my im- 
pression is that the problem has resolved itself into one 
largely of after-care, as practically all of the cases are on 
a level at which they should remain stationary. Unless an- 
other epidemic occurs, few surgical problems will arise in 
these cases ; but the continuance of these patients as active, 
useful individuals depends upon their being carefully and 
persistently followed up. In other words, from being chiefly 
a surgical problem, the work has become largely a problem 
of supervision and after-care. 



ORGANIZATION, AIM, AND PLAN OF WORK 

OF THE AFTER-CARE DEPARTMENT 

FOR POLIOMYELITIS 

By Bertha E. Weisbrod* 

THE After-Care Department undertakes the supervis- 
ion of every case of poliomyelitis in the State of Ver- 
mont from the time the quarantine is lifted until the 
best possible recovery has been made. The cases divide 
themselves into two main groups: old cases, in which the 
onset was prior to the establishment of the department and 
in which varying degrees of paralysis or deformity are al- 
ready existent; and new cases, those of recent onset in 
which treatment may be supervised from the beginning and 
paralysis and deformity to 1 the greatest possible extent pre- 
vented. Each acute case which is reported to the Board of 
Health has the benefit of the highly specialized knowledge 
of the department which works in close cooperation with 
the attending physician, giving advice as to treatment and 
preventive work, and, as soon as the acute stage is past, 
assuming full charge of the after-care until as complete a 
recovery as possible is assured. 

The department is affiliated with the Board of Health of 
the State of Vermont, which provides it with office space, 
and it is under the general direction of Dr. Robert W. Lovett 
of Boston. The personnel in Vermont consists of a director, 
in complete charge of the work itself and responsible for 
the organization and maintenance of its subsidiary activi- 
ties; an assistant in the field work; a vocational teacher; 
and a secretary. 



*Director, Division of Poliomyelitis After-Care, Vermont Department of Public Health. 

302 



ORGANIZATION, AIM, AND PLAN OF WORK 303 

Each year mid-summer clinics are held at nine centers 
in different parts of the state in charge of Dr. Lovett or his 
associate, Dr. Ober, with the assistance of the field workers. 
At these clinics each case is diagnosed by the physician in 
charge, the necessary treatment is prescribed, parents and 
•local physicians are advised as to the best methods to be 
pursued, and the exact status of each case under the super- 
vision of the department is ascertained and recorded at this 
time. Patients who require special examination before the 
time of the annual clinics may be taken to Boston where Dr. 
Lovett or Dr. Ober is always available for consultation. Sub- 
sidiary clinics are held in the spring and fall in charge of 
the director and her assistant. At this time improvement is 
noted, changes in treatment indicated, and apparatus ad- 
justed. ^ 

After the clinical examinations a careful follow-up of the 
treatment in the homes of the patients is maintained by the 
field workers. Each of these workers is provided with a car 
which enables her to cover a large area without waste of 
time. During the winter months when the roads are im- 
passable for automobiles, the necessity of traveling by rail 
greatly reduces the number of visits which can be made each 
month. In addition to home visits, some of the patients call 
at the office for consultation, for special examination, or for 
adjustment of apparatus. Through these frequent visits, 
both home and office, the workers are enabled to see that the 
prescribed treatment is carried out, to give muscle training 
exercises, to measure for and adjust apparatus, and other- 
wise to give careful supervision to the patients in their 
charge. 

In the cases where the clinical examination indicates that 
an operation is advisable, it is the duty of the director to 
consult with the family of the patient and obtain the neces- 
sary consent. This often requires a certain amount of edu- 
cational work before it can be accomplished. The director 



304 INFANTILE PARALYSIS IN VERMONT 

then makes all arrangements for the operation, secures hos- 
pital accommodations, assumes full charge of the patient 
on the trip to and from the hospital, keeps the family in- 
formed of progress and when the operation is over and the 
patient back at home, sees that proper post-operative care 
is given. In order to secure the best possible care for its 
operative cases, the Af ter-Care Department has found it ad- 
visable to maintain a hospital of its own in Boston during 
the winter where the patients may be kept under its direct 
supervision. The director of the department is required to 
secure this hospital, equip it, obtain the staff and after it is 
running to keep it under her general supervision. In addi- 
tion to the cases treated in this hospital, there are many pa- 
tients cared for in local hospitals, in the Children's Hospital 
in Boston, and in the Hospital for the Ruptured and Crip- 
pled in New York. 

The department also has its own appliance shop where 
most of the apparatus used for the Vermont cases is made. 
This is located in Burlington at the University. The braces 
are made directly from the measurements taken by the field 
workers so that the delay and uncertainty of ordering by 
mail are eliminated. 

Another part of the work of the After-Care Department 
is Ormsbee House, a school and home for crippled children, 
designed especially for their use and with every provision 
for their welfare. This school is intended for children whose 
homes do not offer the best conditions for successful treat- 
ment and is free to those whose parents are unable to pay 
for their care. Ormsbee House has its own superintendent 
and staff but is under the general supervision of the After- 
Care Department. 

The department gives vocational training to those of its 
patients who are unable to contribute materially to their 
own support. This part of the work is carried on by a voca- 
tional teacher who provides materials at cost and markets 



ORGANIZATION, AIM, AND PLAN OF WORK 305 

the finished articles until each patient is in a position to do 
this for himself. 

In addition to the organization and carrying on of the 
work itself, the director is also responsible for the manage- 
ment of the office. There are, of course, innumerable details 
of office routine incidental to managing the various activi- 
ties of the department, and all the data are recorded as 
clearly and simply as possible. 

A file (with card index) contains the patients* cards in 
simple alphabetical order, according to the name of the pa- 
tient and grouped geographically according to clinic. The 
patient's card consists of two parts: a name card contain- 
ing all the essential facts withS regard to the patient at the 
time of his admission, and an action card which contains 
the record of treatment. The name card has on the face the 
name of patient; name of parent or guardian, and address; 
name of attending physician; clinic attended; date of ad- 
mission; onset of disability; diagnosis; and treatment pre- 
scribed. On the reverse side of this card is a list of essential 
facts which may be checked for statistical purposes and 
which will tell at a glance the status of the patient. The 
action card contains the record of visits made, treatment 
prescribed, results, etc. There is a cross-filing system which 
indicates which patients are in hospitals and which patients 
are having apparatus made or repaired. This card file is 
adequate for the ordinary daily routine, but in order to have 
more detailed information for the clinics, there is an addi- 
tional file containing a folder for each patient and arranged 
according to the same alphabetic, geographic system and for 
which the same card index (which also serves as a mailing 
list) is used. Each of these folders contains a complete mus- 
cle chart for the patient and all papers relating to case his- 
tory. 

The vocational file is also a simple, alphabetical file con- 



306 INFANTILE PARALYSIS IN VERMONT 

taining work cards for each patient with complete record 
of material issued, work finished, on hand, sold, etc., and ac- 
tion cards containing record of visits made by vocational 
assistant, supervision given, etc. 

Besides the daily records made for the office itself, a de- 
tailed report is rendered monthly and a full report annually 
to the State Board of Health. 

Through the various branches of its work, the depart- 
ment endeavors to give the best possible surgical treatment 
and physical care to its patients, to secure home conditions 
which will render a satisfactory recovery possible, and to 
establish the patient as a useful member of the community. 
This service is, of course, without charge and in the opera- 
tive cases, where there are hospital or apparatus expenses 
to be met, if the patient is unable to pay the full amount, 
financial assistance is given. Beside carrying on the actual 
work, the department makes every effort to record all re- 
sults accurately and to keep such records clear and imme- 
diately available, so that the statistics compiled therefrom 
may prove of definite value in the further pursuit of the 
work and may serve as a true basis of comparison for any 
future experiment along the same lines. 



HISTORY OF THE WORK OF THE RESEARCH 

LABORATORY 

By W. L. Aycock, M.D. 

THE year 1914 will be memorable in the public health 
records of Vermont, not only because of the wide- 
spread and serious outbreak of poliomyelitis which 
swept the state in that year, but also because this dire event 
was responsible for the development of a form of practical 
philanthropy previously unknown in Vermont. An anony- 
mous friend placed at the disposal of the State Board of 
Health a considerable sum of money to be used for the pur- 
pose of investigating the nature of this baffling malady and 
placing the benefits of the best possible methods of treat- 
ment within the reach of those afflicted with the disease. 
Dr. Caverly had called attention to infantile paralysis as a 
problem of distinct importance from a public health stand- 
point as early as 1894, when he recorded the first epidemic 
which occurred in this country. From that time until 1910, 
the disease did not reappear in epidemic form, although 
occasional cases were encountered in the state. In the mean- 
time, the disease had become prevalent in neighboring 
states, especially during the years from 1907 to 1910. Upon 
the reappearance of the disease in Vermont in 1910, active 
measures were taken to guard against it. It was made a 
reportable disease and a systematic epidemiological study 
was begun by Dr. Caverly. His investigations, which were 
recorded in his annual reports and are reprinted in this 
book, provided an insight into the behavior of epidemic 
poliomyelitis which was invaluable in outlining the work 
to be undertaken under the gift which came to the state in 
1914. 

307 



308 INFANTILE PARALYSIS IN VERMONT 

After conferring with Dr. Simon Flexner, Director of the 
Rockefeller Institute for Medical Research, and with Dr. 
Robert W. Lovett, Professor of Orthopedic Surgery in Har- 
vard University Medical School, three distinct lines of work 
were undertaken: (1) the care of patients in the acute and 
chronic stages of the disease; (2) preventive work, consist- 
ing of study and investigations of cases and epidemics, as- 
sistance to physicians in diagnosis, and the regulation of 
quarantine; (3) experimental investigations of the nature, 
mode of transmission, treatment and prevention of the dis- 
ease. 

It was at once realized that the success of an organized 
effort of this kind would depend in a large measure upon 
the cooperation of practicing physicians of the state who 
are the first to come in contact with cases of the disease. A 
campaign was instituted for the purpose of bringing to the 
medical profession of the state the most advanced knowl- 
edge in regard to the diagnosis, treatment, and prevention 
of this disease. It should be remembered that at this time 
epidemic poliomyelitis was still a comparatively rare dis- 
ease in most sections of the state. In pursuing this cam- 
paign the State Board of Health had the services of Dr. 
Francis R. Fraser of the Presbyterian Hospital of New 
York City. Meetings were held at different points in the 
state and everything possible was done to familiarize the 
medical profession with the disease. Much was accom- 
plished in the way of stimulating interest in efforts to con- 
trol the spread of the infection. Later, this portion of the 
work was incorporated with other departments of the State 
Board of Health whose work brings them in contact with 
physicians throughout the state. They provide information 
regarding the disease which would not be available other- 
wise. 

That portion of the work which has to deal with acute 
cases, that is, the epidemiologic investigation, diagnosis and 



HISTORY OF WORK OF RESEARCH LABORATORY 309 

treatment of the acute stage of the disease, and the experi- 
mental investigation of the infectious agent, has been car- 
ried on by the Research Laboratory of the State Board of 
Health. This work was organized by Dr. Harold L. Amoss 
of the Rockefeller Institute for Medical Research in 1914, 
and since that time it has been carried on under his super- 
vision. In 1914 and 1915 the work was conducted by Dr. 
E. S. Towne; from 1915 to 1918 by Dr. Edward Taylor; 
during 1918 by Dr. Peter Noe; and since 1919 by Dr. W. L. 
Aycock. During his lifetime, Dr. Caverly was in close 
touch with the activities of this department and was always 
a source of inspiration to those who labored under his direc- 
tion upon its difficult and sometimes discouraging problems. 
Since it was first put into operation, now nearly ten years 
ago, the original plan of the work has been maintained 
without essential changes- — a tribute to the wisdom and 
foresight of its founder, Dr. Caverly. 

The diagnostic facilities of the laboratory have been con- 
stantly available to all portions of the state, a fact which 
is of great value in checking the spread of the infection, in 
that it makes possible the recognition of even the more 
obscure cases, which is of prime importance in any cam- 
paign for the suppression of disease. In order that this 
service might be available for the examination of cases 
early in the course of the disease, a portable laboratory out- 
fit which may be carried to the patient's home is used. 
Because of the size of Vermont a call to any part of the 
state is responded to within a day, usually by automobile, 
and the laboratory examinations are made at the bedside. 
Thus, by investigating cases or suspected cases very early 
in the disease, a splendid opportunity is afforded for carry- 
ing out uniform sanitary measures and treatment by special 
methods. It is by reason of this early contact with the acute 
case that the laboratory staff has, been able to use as much 
convalescent serum as has been obtainable for the treat- 



310 INFANTILE PARALYSIS IN VERMONT 

ment of cases. Thus, this portion of the work, which has 
been known as the "field work," brings the laboratory into 
contact with all the problems of the disease, and provides 
the basis for the research work. 

Actual experience with the disease has pointed out many 
problems which have been the subject of investigation in 
the laboratory. In a general way, the experimental investi- 
gations have been directed toward the solution of the prac- 
tical problems of poliomyelitis. This work has already 
served to fill in some of the important gaps in the knowledge 
of the disease. Some of the results of the laboratory inves- 
tigations which have been published in various journals are 
reprinted elsewhere in this volume. Efforts have been made 
in various ways to produce serum active against the virus. 
Again, the possibility of producing a vaccine or immune 
serum by the use of pure cultures led to many attempts to 
cultivate the virus artificially. This work, which has thus 
far been unsuccessful, led in its turn to a series of experi- 
ments in which cultivation of the virus was attempted by 
reproducing as nearly as possible the conditions under 
which it multiplies when inoculated into monkeys. The virus 
was inoculated into culture media contained in collodion 
sacs, which were implanted into animals. 

These methods failed to produce a more potent serum for 
the treatment of the disease, so attention was directed to- 
ward the methods used in the administration of convales- 
cent serum, which has a destructive action on the virus. A 
study of the secretion and circulation of cerebrospinal fluid 
indicated that administration of serum by the usual meth- 
ods does not insure the greatest action of the serum upon 
the virus. Furthermore, within recent years certain alter- 
ations have been experimentally produced in the circulation 
of cerebrospinal fluid which suggested possibilities in con- 
nection with the problem of securing a more adequate de- 
struction of virus by serum. This work is still being carried 
on. 



HISTORY OF WORK OF RESEARCH LABORATORY 311 

In a similar manner many other phases of the problem 
have been pursued. Many substances, chemical and bio- 
logical, have been tested in attempts to find some destruc- 
tive agent which could be applied to the prevention or treat- 
ment of the disease; methods for detecting carriers have 
been studied; and the mechanism through which the virus 
is able to set up infection has been investigated, along with 
the question of susceptibility to infection. In the hope that 
certain analogies between the virus of poliomyelitis and 
that of other diseases might point to a solution of some of 
the problems which have arisen, experiments which were 
not possible with this virus have been carried on with other 
infectious agents which bear a similarity to this virus. 
Many of the experiments have given valuable results, while 
others have failed entirely; still other questions studied in 
the light of our present knowledge will require repetition 
as the progress of the sciences of bacteriology and path- 
ology make available improved methods for carrying out 
such investigations. 

Thus the work has progressed, the practical side of the 
work serving its purpose toward prevention of the disease 
and the compilation of data obtained in the field continuous- 
ly pointing to problems which are made the subject of in- 
vestigation in the laboratory. 

Any organized effort directed toward the eradication of 
epidemic disease and carried on in a manner calculated to 
be for the public welfare necessitates certain restrictions 
on the ordinary pursuits of individuals and communities 
which may be a matter of serious inconvenience to them. 
Thus the work of this organization, in the effort to lessen 
the occurrence of poliomyelitis, calls upon the physician, 
individual and community alike, to take part in a way which 
often amounts to a great sacrifice. On every hand there has 
been encountered a willingness to undergo any amount of 
hardship to lessen the menace of this dread disease. 



THE CARE AND TREATMENT 
OF POLIOMYELITIS IN VERMONT* 

W. L. Aycock, M.D. 

1HAVE been invited to speak here of the care and treat- 
ment of Acute Anterior Poliomyelitis. I assume that 
what is desired at a conference of this sort is a discus- 
sion of these features of the disease as they apply to the 
general problem rather than to the individual case. 

It is an obvious truism that the control of communicable 
diseases is of vital importance to the community in which 
such diseases occur. A disease which can be transmitted 
from one individual to others by any means whatsoever is 
a matter which concerns not only the individual who has it, 
but also those to whom it might be transmitted. Further- 
more, all diseases which are transmitted by natural means 
are capable of reaching epidemic proportions, in which case 
they become a menace to a greater number of people. It fol- 
lows then that the appearance of a communicable disease is 
a source of danger to all, and, realizing this indication of a 
possible widespread outbreak, the people of a community 
make certain attempts to avoid the disease. This interest 
which a community takes in its state of health is nothing 
new. As far back as history goes we find evidence that com- 
munities have made efforts to rid themselves of epidemic 
diseases. The cry "Unclean" was one of the earliest quaran- 
tine measures. Its success was due to its universal rigid en- 
forcement and to this day it stands out as one of the most 
thorough public health measures. Using a similar method 
we could quickly drive out any communicable disease with 
which we have to deal today. In a few instances, the houses 



*Read before the Conference of the Vermont State Medical Society and the Public 
Health Workers, Jan. 11, 1922. 

312 



CARE AND TREATMENT OF POLIOMYELITIS 313 

in which the dead have lain have been burned down to pre- 
vent the diffusion of the contagion. There was a time when 
ships were sunk to destroy the supposed contagion on board. 
Before the days of vaccination the people concerned them- 
selves with the problem of smallpox to the extent that they 
had themselves inoculated with it in order to develop the 
disease and have it over with at some convenient time. In- 
deed a remnant of this primitive attempt at handling the 
question of communicable diseases persists in some quar- 
ters. There are still found those who like to expose their 
children to some of the common infectious diseases at some 
time when it is most convenient to get over with what they 
consider the inevitable. These represent the attempts of 
the laity in earlier times to handle their medical problems 
unaided. 

With the development of the medical profession, the prob- 
lem has been turned over to them, and our communities now 
look to us for protection against ravaging diseases. With 
the increasing knowledge on the part of the public that 
many diseases are preventable, for which they are indebted 
to the medical profession, this demand is growing. How 
are we to meet it? 

In order to control or eradicate a communicable disease, 
its behavior must be understood. Its cause must be known, 
it must be capable of identification, the manner in which it 
leaves the sick, spreads, and gains its footing in the healthy 
must be understood. When these things are learned, the 
remedy is to be sought. Something which will cure the sick 
must be found. A way to prevent its leaving the sick, 
spreading, or gaining entrance into the healthy individual 
must be contrived. These are the things which must be dis- 
covered before the demands for protection can be satisfied 
and this knowledge can only be acquired by the collection 
and correlation of observations and by testing possible hy- 
potheses in the experimental laboratory. 



314 INFANTILE PARALYSIS IN VERMONT 

It is in this manner that the great strides in the preven- 
tion of epidemic diseases have been made. The rapid dis- 
appearance of malaria is following the discovery of the 
mosquito as its carrier, and the same is true of yellow fever. 
The eradication of smallpox depends only upon the thor- 
oughness with which we use the methods which have been 
placed at our disposal. Typhoid fever has quickly yielded 
to the methods which have been developed for the control 
of the spread of its organism and widespread vaccination 
against it. Rabies has succumbed to Pasteur's wonderful 
discovery. There are many other examples, all the product 
of organized efforts to collect and correlate observations 
and to test various hypotheses experimentally. 

There remain unsolved many other similar problems, 
notable among them tuberculosis, the pneumonias, venereal 
diseases, and the infectious diseases of childhood. Poliomye- 
litis is only one of them, and I wish to have you consider 
with me the present state of our knowledge of this disease 
and the principles underlying the efforts which are being 
made in Vermont to check its ravages. 

Since the first epidemic of considerable size in this coun- 
try, which occurred in Vermont in 1894, and which was 
described in medical literature by the late Doctor Charles S. 
Caverly, hardly a year has passed during which poliomyeli- 
tis has not appeared within this state. Since 1907 it has 
been on the increase in this country and Vermont has borne 
its share of this increase. In 1921, there were reported in 
the United States over 5,000 cases and 60 of these were in 
Vermont. 

From the standpoint of the individual, poliomyelitis 
means death in from 10 to 20 per cent of cases, permanent 
total disability in about 5 per cent, and more or less crip- 
pling in over 50 per cent. 

From the standpoint of the community, every initial case 
in a given section (based on Vermont statistics for 1921) 



CARE AND TREATMENT OF POLIOMYELITIS 315 

has been followed within three weeks by an average of three 
other cases in the same vicinity. The first appearance of 
the disease in any locality is thus an extremely important 
event because it is a forecast of other cases. 

These features of the disease in addition to the fact that 
medical science cannot, with its present knowledge, prevent 
or cure the paralysis which results from it, are the strong- 
est arguments for using whatever knowledge we now pos- 
sess to prevent the disease and for adding to that knowledge 
by every possible means. 

Poliomyelitis is an infectious and communicable disease 
which is caused by the invasion of the central nervous or- 
gans by a minute filterable organism. 

The virus exists in the central nervous organs and upon 
the mucous membrane of the nose and throat and of the in- 
testines in persons suffering from the disease either in its 
paralytic or abortive form. It is also present upon the mu- 
cous membranes of the nose and throat of healthy persons 
who have been in intimate contact with acute cases, and 
such contaminated persons, without falling ill themselves, 
may convey the virus to other persons who develop the dis- 
ease. 

The virus is known to leave the infected human body in 
the secretions of the nose, throat, and intestines, and to 
escape from the contaminated healthy person in the secre- 
tions of the nose and throat. 

The chief mode of demonstrated conveyance is through 
the agency of human beings, the conveyors being the per- 
sons ill with the disease in any of its several forms and 
healthy persons contaminated with the virus through con- 
tact with the sick. 

While other modes of infection may operate, the main 
avenue of entrance into the body seems to be by way of the 
upper respiratory mucous membrane. 

This comprises, in brief, our knowledge of the manner 



316 INFANTILE PARALYSIS IN VERMONT 

in which poliomyelitis spreads, and it has been acquired 
through the collection and correlation of observations and 
by the testing of various hypotheses in the experimental 
laboratory. Upon this knowledge is based the means of con- 
trol which we can now bring to bear upon the disease, 
namely, the prompt discovery and isolation of those sick 
with any form of the disease and the sanitary control of 
those who have been in contact with the sick. 

More remains to be learned about the disease before we 
can fulfill the demand of the public for protection against it. 
There exists, at present, no safe method of preventive in- 
oculation or vaccination and no practical method of specific 
treatment. How can the disease be detected earlier in its 
course? How can the abortive case be detected with cer- 
tainty? Are there other modes of transmission which have 
not yet been demonstrated? How can a healthy carrier be 
detected and how long may the virus be carried ? Is there a 
way to prevent the transmission of the disease by removing 
the virus from the nasal passages or can the nasal mucous 
membrane be protected from the entrance of the virus? 
How can the organism responsible for the disease be arti- 
ficially grown so that it will be available for experiments 
looking toward the production of a serum or vaccine? If, 
and when, it is so cultivated, can a serum or vaccine be 
made ? If no way can be found to prevent the disease, what 
can be done to lessen its disastrous results? What is the di- 
rect cause of the injury to the nerve cell which gives rise to 
the paralysis? Can anything be done to lessen or prevent 
this injury? 

In the answers to these questions, in addition to the most 
thorough application of our present knowledge of the dis- 
ease, lies the ultimate solution of the problem. 

The essentials of this research are: the earliest possible 
diagnosis of every case that appears, the collection and 
compilation of information regarding the date, location, the 



CARE AND TREATMENT OF POLIOMYELITIS 317 

surrounding conditions, and the significance of the relation 
of every case to other cases in the same or distant localities, 
and the testing of any hypothesis which this information 
points to in the laboratory. Success depends upon the in- 
dividual practicing physician. That he may better perform 
his task, he must be provided with whatever aid he does not 
possess in order to make the earliest possible diagnosis and 
to collect the required information. 

These are the principles underlying the work which is 
being done in Vermont. Thanks to the work of Dr. Caverly 
and the generosity of an anonymous donor, the practicing 
profession in Vermont now constitutes a group better able 
to recognize and handle the problem of poliomyelitis and to 
increase our knowledge of it than exists in any other state. 
This is the best guaranty our state can have for its safety. 



NEUTRALIZATION OF THE VIRUS OF 
POLIOMYELITIS BY NASAL WASHINGS* 

By Harold L. Amoss, M.D. 

and 

Edward Taylor, M.D. 

(From the Research Laboratory^ of the Vermont State 
Board of Health, Burlington.) 

THE occurrence of the infectious microorganism of 
poliomyelitis — the virus, so called — in the mucous 
membranes of the nasopharynx and in their secretions 
is now firmly established. 1 ' 2 Not only may the virus be de- 
monstrated by inoculation tests during the acute period 3 
of the disease, but it is known to persist there in some cases 
for many months after convalescence 4 ' 5 and, conversely, it 
has been detected in certain instances in the washings from 
the nasopharynx of healthy persons who have been in inti- 
mate contact with the acutely ill. 6 Finally, the fact has been 
determined by experiment that when the virus is introduced 
directly into the central nervous tissues wherein it multi- 
plies, it also appears in the mucous membranes of the nose 
and throat. These facts indicate that the nasopharyngeal 
mucous membranes play an important part in the pathology 
of epidemic poliomyelitis; and the weight of opinion today 
is to the effect that the ingress and egress of the virus take 
place by way of these structures. 



^Reprinted from The Journal of Experimental Medicine, April 1, 1917, Volume XXV, 
No. 4, pp. 507-523. 

tMaintained by a special fund privately donated. 

1. Flexner, S., and Lewis, P. A., J. Am. Med. Assn., 1910, liv, 535. 

2. Landsteiner, K., Levaditi, C, and Pastia, 0., Semaine med., 1911, xxxi, 296. 

3. Flexner, S., and Clark, P. F., J. Am. Med. Assn., 1911, lvii, 1685. Landsteiner, Leva- 
diti, and Danulesco, Compt. rend. Soc. biol., 1911, lxxi, 558. 

4. Lucas, W. P., and Osgood, R. B., J. Am. Med. Assn., 1913, lx, 1611. 

5. Kling, C, Pettersson, A., Wernstedt, W., and Josefson, A., Communications Inst. med. 
ttat a Stockholm, 1912, iii. 

6. Flexner, S., Clark, P. F., and Fraser, F. R., J. Am. Med. Assn., 1913, lx, 201. Kling, 
C, and Pettersson, A., Deutsch. med. Woch., 1914, xl, 320. 

318 



NASAL WASHINGS IN POLIOMYELITIS 319 

One of the most important questions arising out of the 
data presented above is that relating to the so-called healthy- 
carriers of the virus, and for two main reasons. The healthy 
carriers may be the means of transporting the virus to 
other persons less resistant who may develop poliomyelitis ; 
or the carrier, healthy when first contaminated, may subse- 
quently develop the infection. At present the means at our 
disposal for studying the subject of virus carriers are so 
imperfect that no adequate notion of their number and dis- 
tribution can be obtained. As long as the inoculation of 
monkeys with the washings from the nasopharynx must be 
relied upon to furnish this information, complete knowl- 
edge cannot be acquired. 

There is, however, another fact which may prove to be 
significant. Assuming that during the prevalence of epi- 
demics, many persons become contaminated with the virus, 
the question arises whether this condition need necessarily 
be either a menace to the contaminated person himself or to 
others. The answer to this question may lie in the reaction 
of the secretions of the nasopharyngeal mucous membranes 
to the virus present upon them. It is possible that in one 
person the secretions do not exercise a harmful action on 
the virus, while in another they do. This injurious action 
upon the virus may be of the nature of a protection to the 
individual contaminated as well as to the public in general. 

It has often been observed that washings made from the 
nasopharynx may be ineffective when introduced into mon- 
keys, and the lack of power to cause infection has been at- 
tributed to insufficient quantity or low infective power of 
the virus believed to be contained in the secretions removed. 
No note has been taken of the possibility that the washings 
are ineffective because the secretions of the mucous mem- 
brane are destructive or neutralizing to the virus of polio- 
myelitis. While this possible action may affect the inocula- 
tion tests in cases of acute poliomyelitis, it would be far 



320 INFANTILE PARALYSIS IN VERMONT 

more likely to be operative in the supposed carrier because 
of the small amount of virus and the probability of dimin- 
ished virulence in the latter. Because of these considera- 
tions, a series of experiments was carried out to determine 
(1) the smallest quantity of a standard virus which can be 
detected in washings, and (2) the action of the washings of 
different persons upon the virus itself. 

Reference has already been made to the fact that nasal 
washings, of contacts especially, have in a few instances 
produced poliomyelitis when injected into monkeys. As the 
virus obtained directly from human beings possesses low 
virulence for monkeys, and is injected greatly diluted, the 
small number of successful inoculations is significant. Tests 
were made to determine the effect of concentration of wash- 
ings on the activity of the virus. Amounts of virus which 
would certainly produce the infection if injected directly 
were added to a filtered washing fluid obtained from per- 
sons not having been exposed to the infection. The mixtures 
were separately reduced to small volume in vacuo at low 
temperatures and injected into monkeys. The results ob- 
tained were variable, for reasons which at first were not 
obvious, but the tests nevertheless showed that the filtered 
virus in certain amounts may withstand concentration in 
washing fluids without losing entirely its infective power. 

EXPERIMENTAL 

Experiment 1. — The nasal cavities of a normal adult, 
H. L., were rinsed thoroughly with 50 cc. of distilled water. 
The collected fluids were passed through a Berkefeld filter 
and 0.2 cc. of a Berkefeld filtrate of a 5 per cent suspension 
of poliomyelitic brain was added. The mixture was reduced 
in vacuo at 37° C. to 4 cc. and injected intracranially, under 
ether anesthesia, into a Macacus rhesus. The monkey be- 
came partially paralyzed on the 10th day, completely pros- 
trated on the 12th day, and died on the 14th day. Typical 
lesions of poliomyelitis were present. 

Experiment 2. — The washings of a normal adult, W. T., 
were obtained in the manner described above. To the fil- 



NASAL WASHINGS IN POLIOMYELITIS 321 

tered fluid was added 0.5 cc. of a Berkef eld filtrate of active 
virus. The mixture was concentrated at 37 °C. in vacuo and 
injected intracranially, under ether anesthesia, into a Ma- 
cacus rhesus. The monkey remained well. As the result of 
a later protection test the monkey died of poliomyelitis 
after an appropriate injection of potent virus. 

Filtration through Berkefeld or other porcelain filters is 
undertaken to remove the bacteria always present in the 
nasal and buccal secretions. But the bacteria can be either 
killed or their multiplication inhibited by certain antiseptic 
chemicals which affect to a less extent the virus of poliomye- 
litis. Thus 0.5 per cent carbolic acid destroys pyogenic bac- 
teria in tissues and leaves the virus intact. Experiments also 
showed that ether acted more severely on the ordinary bac- 
teria than on the virus. In order, therefore, to obviate any 
loss of virus which might result from its retention by the 
filters, ether was employed to sterilize the washings. Pre- 
liminary tests showed that contact of ether for 20 hours 
with the virus contained in an emulsion of the spinal cord 
does not destroy it. The test made with washings indicates 
that while a shorter exposure may not kill all the bacteria, 
yet they are so greatly diminished that no ordinary infec- 
tion is produced on inoculation into monkeys. And yet, as 
the experiments which follow show, while the filtrate con- 
tained in 0.8 per cent salt solution is active after the ether 
treatment, that mixed with the nasal washings is ineffec- 
tive. The ineffectiveness at first believed to have been due 
to injury of the virus by the ether or too great dilution of 
the fluid inoculated, is now probably explicable in other 
ways. 

Experiment 3. — 1.8 cc. of a Berkefeld filtrate of active 
virus were added to 4.2 cc. of isotonic sodium chloride solu- 
tion and 1 cc. of chemically pure ether. The mixture was 
shaken for 20 hours at room temperature. The ether was 
allowed to evaporate and 1 cc. of the remaining mixture, 
representing 0.3 cc. of virus filtrate, was injected intra- 



322 INFANTILE PARALYSIS IN VERMONT 

cranially, under ether anesthesia, into a Macacus rhesus. 
The monkey was almost prostrate on the 7th day, complete- 
ly prostrate on the 8th, and etherized when moribund on the 
10th day. The lesions were typical. 

Experiment Jf. — To 100 cc. of nasal washings from two 
normal adults was added 1 cc. of a Berkefeld filtrate of 
mixed virus, 0.1 cc. of which produced paralysis in the con- 
trol monkey in 7 days. 5 cc. of chemically pure ether were 
added to the mixture and the whole was shaken for 20 
hours at room temperature. The ether was allowed to evap- 
orate, and 2 cc. of the mixture were injected intracerebral^ 
and 98 cc. intraperitoneal^, under ether anesthesia, into a 
Macacus rhesus. The monkey remained well. 

Berkefeld filters withhold even very minute particles in 
greater amount when they are contained within a viscid or 
glutinous liquid. All the washings contain mucus; hence a 
procedure was adopted to modify the mucin so as to avoid 
this difficulty without at the same time injuring unduly the 
virus itself. The procedure consists in treating the wash- 
ings with sodium bicarbonate, filtering, and then concen- 
trating in vacuo at 37° C. The virus is little injured. When 
0.1 cc. of a filtrate, which is on the limits of a minimum 
lethal dose, is used, the resulting concentrated fluid may be 
ineff ective ; when 0.2 to 0.3 cc. is employed infection results. 
The next protocol in which 0.3 cc. of filtrate was used is 
an example of the method, but identical effects were ob- 
tained with 0.2 cc. 

Experiment 5. — The nasal cavity of a normal adult was 
thoroughly syringed with 50 cc. of sterile distilled water. 
0.3 cc. of a Berkefeld filtrate of virus was added, and, after 
thorough mixing, 0.25 gm. of dry sodium bicarbonate was 
added and the fluid shaken for 20 minutes with beads. After 
centrifugation at high speed for 3 minutes the fluid was de- 
canted and passed through a Berkefeld candle V. The pre- 
cipitate was washed and filtered through the same candle. 
The mixture of the filtrates was reduced in vacuo at 36° C. 
to a volume of 2 cc, which with rinsing water was trans- 
ferred to a collodion sac and dialyzed for 1 hour. 

Under ether anesthesia, a Macacus rhesus received half 



NASAL WASHINGS IN POLIOMYELITIS 323 

(3.5 cc.) of the resulting liquid into the left, and the other 
half into the right cerebral hemisphere. No symptoms were 
observed until the 6th day when the monkey became ataxic 
and excitable. The monkey was prostrate on the 8th day 
and died on the 14th day after injection. Typical micro- 
scopic lesions of poliomyelitis were present. 

The treatment of the washings with sodium bicarbonate 
renders the effect of the inoculation certain when the use 
of larger quantities of the virus with washings alone fails 
to confer infection. The probable cause of the discrepancy 
has become apparent only after a more minute study of the 
properties of the nasal washings ; but that the sodium bicar- 
bonate acts either by allowing more virus to pass through 
the filter or by removing certain inhibitory influences ex- 
erted by the washings is directly indicated. 

INACTIVATING EFFECTS OF NASAL SECRETIONS 
UPON THE VIRUS 

The results of the preceding experiments, which con- 
tained obvious discrepancies, suggested a closer study of the 
secretions of the nose and pharynx from the standpoint of 
a possible inhibiting or neutralizing action on the virus of 
poliomyelitis. For this purpose a variety of persons was 
studied; some were suffering from acute poliomyelitis, and 
the others were apparently normal individuals. 

The nasopharynx was rinsed with double distilled water 
and the washings were fractionally sterilized by heating to 
60°C. for 3 successive days. Each person's specimen was 
handled separately. In earlier experiments, in order to 
economize animals, the washings of several persons were 
often mixed. It now seems not improbable that discordant 
results follow this procedure. The virus employed was ob- 
tained by filtering a 5 per cent suspension of glycerolated 
poliomyelitic monkey spinal cord. To each 30 cc. of the 
washing 7.5 cc. of the filtered virus were added. The mix- 



324 



INFANTILE PARALYSIS IN VERMONT 



ture was then incubated at 37° C. for 24 hours. Control mix- 
tures of virus and distilled water were subjected to the 
same incubation. Each cubic centimeter of the mixtures 
then contained 0.2 cc. of the filtrate, or at least two mini- 
mum lethal doses of the virus. The results of the first tests 
are given in Table I. 

Table I. 
Inactivating Effects of Nasal Secretions upon the Virus 













i-Sg ' 

w 3 










In contact with 


Method of 
sterilising 


it** 








Dose 


nasal washings 


nasal wash- 


^gM 




Date 


Virus 


of virus 


from 


ings before 


LsJlb 


Result 




No. 


filtrate 




addition of 
virus 


Temperat 
virus pi 
washim 
bated fc 




1916 




cc. 






°C. 




Feb. 16 


32 


0.2 


Baby C; age 3 
yrs. Acute 
stage of polio- 
myelitis 


Heated 1 hr. 
at 60° C. 

on 3 success- 
ive days 


37 


Monkey died. 
Typical poli- 
omyelitic le- 
sions 


Mar. 11 


32 


0.2 


W. T., normal 
adult; age 39 
yrs. 


<< 


37 


Monkey re- 
mained well 


June 2 


48 


0.2 


C.A.R.andL.M. 
McK. (mixed), 
normal adults 


C( 


37 


(C 


" 2 


48 


0.2 


<< 


(C 


4 


St 


« 2 


48 


0.2 


H. E. G., normal 
adult 


<« 


37 


<« 



The results of this experiment suggest that the nasal wash- 
ings of a person suffering from acute poliomyelitis may 
exercise no restraining influence upon an active virus, while 
those from healthy persons, under identical conditions of 
preparation, inhibit its activity. 

The next experiment comprised tests on the nasal wash- 
ings of eight apparently healthy persons. The results are 
recorded in Table II. At first sight it appears that of the 
eight specimens of washings, six possessed inhibiting prop- 
erties and two did not. The question arose as to whether 



NASAL WASHINGS IN POLIOMYELITIS 



325 



examination by a rhinologist, who would be unaware of 
the experiment, would disclose any differences in the nasal 
mucous membranes. These examinations, consented to by 

Table II. 

Inactivating Effects of Nasal Secretions of Adults 

















Dose of 




Method of 


IT* -5 8 






Berke- 


In contact with nasal 


sterilizing nasal 


a g <» -^ 
^s> o- 8 <s<i 




Date 


f eld fil- 


washings from 


washings before 


£* S °9 )^ 


Result 




trate of 




addition of 


1 ^.§^ 






Virus 




virus 


S.M3 






1>8 




~v 


£ s? ss S 




1916 


cc. 






°c. 




Apr. 26 


0.2 


M. J. P., normal 


Heated 1 hr. 


37 


Monkey re- 






adult 


at 60° C. on 
3 successive 
days • 




mained well 


" 26 


0.2 


E. S. S., normal adult 


cc 


37 


<< 


" 26 


0.2 


V.H.S., " 


u 


37 


<< 


" 26 


0.2 


C.A.R., " 


<< 


37 


<« 


" 26 


0.2 


L. M. McK., normal 
adult 


(( 


37 


<< 


" 26 


0.2 


G. H., normal adult 


(< 


37 


<< 


" 26 


0.2 


J. P. B., " 


«« 


37 


Monkey died 
Typical le- 
sions 


" 26 


0.2 


H.E.G., " 


<< 


37 


<< 


" 26 


0.2 


Control (sterile 
water) 


it 


37 


<< 


" 26 


0.2 


Control (isotonic salt 
solution) 




37 


Monkey re- 
mained well 



the persons, were kindly undertaken by Dr. M. C. Twitchell. 
His report is summarized in Table III. The only comment 
which the examination calls for is that while the anatomical 
condition of the nasal and adjacent mucosas in the six per- 
sons whose secretions contained inhibiting, inactivating, or 
neutralizing substances were normal, those of the other two 
were more or less pathologic. Just what the relation of this 
fact is to the effects of the secretions on the virus can only 
be surmised; but the test demonstrates that the secretions 
may frequently inhibit the action of the virus in monkeys. 



326 



INFANTILE PARALYSIS IN VERMONT 



Table III. 
Results of Rhinoscopy of the Subjects Recorded in Table II. 



Case No. 



Age 
yrs. 



Report 



1 (M. J. P.) 



23 



Normal nasal respiration; no discharge; no history of 

colds. 
Mild hypertrophic rhinitis. Septum deflected slightly 

to left with large horizontal ridge. 



2 (E. S. S.) 



Normal nasal respiration; no discharge; no throat symp- 
toms; no history of colds. 

Mild hypertrophic rhinitis; vocal bands red (subacute 
laryngitis) . 



3 (V. H. S.) 



24 



Normal nasal respiration; no discharge; no throat symp- 
toms; no history of colds. 

Mild hypertrophic rhinitis. Two spurs on left side of 
septum. 



4 (C. A. R.) 



20 



Normal nasal respiration; no discharge; no throat symp- 
toms; no history of colds. 

Mild hypertrophic rhinitis; septum deflected, half closes 
right nasal cavity. 



5 (L. M. McK.) 



Normal nasal respiration ; no discharge ; no throat symp- 
toms; no history of colds. 

Mild hypertrophic rhinitis; small ulcer on left side of 
septum; horizontal ridge on right side of septum. 



6 (G. H.) 



21 



Normal nasal respiration; no discharge; no throat symp- 
toms; no history of colds. 

Mild hypertrophic rhinitis. Acute pharyngitis of 3 
days' duration. 



7 (J. P. B.) 



Normal nasal respiration but easily obstructed when 
patient has a cold, especially left side of nose; secretion 
drops into throat on arising in the morning. 

Nose narrow; moderate hypertrophic rhinitis; large spur 
on right side of septum touches turbinate; small ulcer 
on left side of septum. 



8 (H. E. G.)* 



Nasal respiration interfered with, especially on right side; 

secretion drops into throat; frequent colds; has cold 

now. 
Septum deflected slightly to right; hypertrophic rhinitis; 

secretions found in right nasal cavity by anterior 

rhinoscopy. Acute pharyngitis and rhinitis. 



*Remarks by Dr. Twitchell: "No. 7 shows the most marked chronic nasal trouble of all, and I should 
class it as moderate rather than severe. No. 8, at the time of examination, had an acute rhinitis and 
an acute pharyngitis. This to a certain extent obscures the findings in this case. Frequent colds are 
a marked feature in the history of chronic rhinitis. No. 8 is the only one giving this history. I should 
conclude that if a chronic rhinitis produces changes in the nasal secretions, No. 8 would be the one 
whose nasal secretions were the most changed." 



NASAL WASHINGS IN POLIOMYELITIS 



327 



The control tests (Table II) show that, under the conditions 
of the experiments, distilled water injures the filtered virus 
less quickly than isotonic salt solution, a fact possibly de- 
pendent upon the different osmotic conditions present in the 
two fluids. The inactivation of the virus through dilution 
by the washings and incubation at 37° C. would appear to 
be excluded by the results of the tests with the secretions 
and with the controls. 

FLUCTUATIONS IN INACTIVATING PROPERTIES 

Attempts were made to ascertain whether the action de- 
scribed is a constant or a variable property of the secre- 
tions. For this purpose washings were made at different 
times, sterilized by discontinuous heating at 60° C, and 
tested against 0.2 cc. of the filtrate which in control tests 
was determined to be potent. The results of these tests are 
given in Table IV. 



Table IV. 

Fluctuations in Inactivating Properties 









Dose 




Date 


Case 


Condition 


of virus 
filtrate 


Result 


1916 






cc. 




Mar. 11 


W. T. 


Apparently normal 


0.2 


Neutralized 


June 16 


a 


cc cc 


0.5 


cc 


July 12 


cc 


cc cc 


0.2 


Failed to neutralize 


Nov. 14 


cc 


cc cc 


0.2 


Neutralized 


Apr. 26 


H. E. G. 


Chronic rhinitis 


0.2 


Failed to neutralize 


June 2 


cc 


" (improved) 


0.2 


Neutralized 


July 12 


cc 


Apparently normal 


0.2 


Failed to neutralize 


Apr. 26 


C. A. R. 


cc 


c 


0.2 


Neutralized 


June 2 


cc 


cc 


• c 


0.2 




Apr. 26 


G. H. 


cc 


c 


0.2 




Dec. 18 


cc 


cc 


EC 


0.2 




Apr. 26 


L. M. McK. 


cc 


C 


0.2 




June 2 


cc 


cc 


c 


0.2 




Apr. 26 


E. S. S. 


cc cc 


0.2 




July 12 


cc 


Acute coryza 


0.2 


Failed to neutralize 



328 INFANTILE PARALYSIS IN VERMONT 

Of four tests with the secretions of W. T., three neutral- 
ized the virus ; of three with those of H. E. G., only one neu- 
tralized it ; of two with washings from C. A. R., G. H., and 
L. M. McK., respectively, all neutralized it, while in the case 
of E. S. S., one neutralized and the other did not. The ani- 
mals that did not come down were subsequently determined 
to be susceptible to inoculation with the virus, so that the 
neutralization effects could not have been simulated by an 
excessive resistance on their part. 

In addition to the tests described, which were conducted 
chiefly with adults, several were made with washings from 
children either healthy or suffering from poliomyelitis. The 
results are not wholly concordant. A larger series may pos- 
sibly clear up the discrepancies. 

Aug. 9, 1916. The washings of C. A., an apparently 
healthy boy, age 14, failed to neutralize 0.2 cc. of filtrate. 

Oct. 23, 1916. The washings of R. J., age 8, taken during 
the acute attack of poliomyelitis, but after immune serum 
had been administered, neutralized 0.2 cc. of filtrate. A con- 
trol monkey developed fatal, typical poliomyelitis. 

Nov. 14, 1916. The washings of R. C., age 8, taken on the 
15th day of the attack of poliomyelitis neutralized 0.2 cc. of 
filtrate. This patient had not been treated with immune 
serum. The control animal developed typical fatal polio- 
myelitis. 

Feb. 16, 1916. The washings of B. C, age 3, taken during 
the acute stage of poliomyelitis, did not neutralize the fil- 
trate. Immune serum had not been given. 

While the number of observations is too small to draw 
definite conclusions, it is obvious that the secretions of ap- 
parently normal persons vary in the so-called neutralizing 
power. Of the two patients with poliomyelitis whose secre- 
tions inhibited action of the filtrate, one had received im- 
mune serum, while the washings were taken from the other 
on the 15th day, or at a time when immunity principles are 
known to be present in the blood. 7 The third child with 



7. Flexner, S., and Amoss, H. L., J. Exp. Med., 1917, xxv, 499. 



NASAL WASHINGS IN POLIOMYELITIS 329 

poliomyelitis yielded washings without neutralizing effect; 
but they were taken earlier (4th day) in the course of the 
infection and at a time when the immunity bodies were 
probably not yet abundantly present. It is possible that 
some relation exists between the presence of definite im- 
munity principles in the circulating blood and the power 
of the nasal washings to neutralize the virus. 

In each series of experiments the potency of the virus was 
established by control experiments, and subsequently all 
the monkeys not showing symptoms were tested for immun- 
ity by appropriate injections of the virus and were all found 
to have been susceptible to infection. Hence the lack of re- 
sponse was not caused by an immunity of the animals em- 
ployed. The secretions of three persons out of six examined 
varied in their power to neutralize 0.2 cc. of the virus fil- 
trate at different times under nearly identical conditions, 
yet the only known clinical differences consisted in the 
presence of a rhinitis which appears to remove the inacti- 
vating power of the secretions. 

FLUCTUATIONS OF THE INACTIVATING POWER IN 
ABNORMAL NASAL CONDITIONS 

In April, 1916, the nasal secretions of E. S. S. neutralized 
0.2 cc. of the virus filtrate, but 3 months later, during an 
attack of acute rhinitis, they did not. The washings from 
C. A. R. twice neutralized the same amount of virus at dif- 
ferent times. Later, immediately following an acute rhini- 
tis, no neutralizing power was observed, but the neutraliz- 
ing power returned in 4 days. 

The washings from H. E. G., taken when rhinoscopy re- 
vealed acute congestion of the nasal mucosa, did not possess 
neutralizing power, but 5 weeks later when the nasal con- 
dition had improved, the washings showed the inactivating 
power. Six weeks after the second test when there were no 
subjective symptoms of rhinitis, the washings failed to neu- 



330 INFANTILE PARALYSIS IN VERMONT 

tralize the virus. Finally, it will be recalled (Table III) 
that out of eight samples of nasal washings taken from ap- 
parently normal adults, only the two which were taken from 
subjects in which rhinoscopy revealed an acute rhinitis 
failed to inactivate the virus. H. E. G. is included in this 
list. 

EFFECT OF FRACTIONAL STERILIZATION AND 
FILTRATION ON INACTIVATION 

The experiments recorded indicate that the washings 
sterilized fractionally or passed through Berkefeld filters 
inactivate or neutralize virus mixed with them in the form 
of a filtrate of a suspension of the spinal cord of a poliomye- 
litic monkey. There can, therefore, be no doubt that the 
procedures do not themselves remove the neutralizing sub- 
stances. Tests were then made to determine the comparative 
or quantitative effects of the procedures. 

The quantity of filtrate employed for inoculation in this 
series of experiments was 0.4 cc, or more than four mini- 
mum lethal doses. The rinsings of the nasopharynx were 
made with redistilled water and they were reduced to a 
uniform volume of 15 cc. by concentration in vacuo. The 
fractional sterilization was carried out at 60 °C. on 3 suc- 
cessive days. The washings and virus were left in contact 
24 hours before the inoculations were made, in some in- 
stances at 37 °C, in others at 4°C. The injections were intra- 
cerebral into rhesus monkeys under ether anesthesia. The 
results are given in Tables V and VI, and the comparison in 
Table VII. 

The results lack absolute consistency. Considering the 
quantity of virus employed, the neutralizing action becomes 
more impressive. The variations in specimens from the 
same individual cannot now be accounted for. The existence 
of acute rhinitis, however, appears to diminish neutralizing 
power. Assuming that the process of neutralization is 



NASAL WASHINGS IN POLIOMYELITIS 331 

brought about by definite chemical bodies, they would seem 
to be thermolabile, since the neutralizing action of filtrates 
is definitely more pronounced than that -of the heated speci- 
mens. Contact at 4°C. appears less effective in bringing 
about the neutralization than at 37 °C. The prolongation of 
the incubation period noted in two instances is probably as- 
sociated with partial but insufficient neutralization to re- 
duce the virus below the minimum lethal dose. 

INFLUENCE OF HEAT 

The results given above suggest that the inactivating in- 
fluence is weakened or destroyed by heat. The following ex- 
periment gives more definite information concerning this 
fact. 

Washings were taken on Nov. 16, 1916, from W.T., whose 
nasal secretions had on several occasions proved neutraliz- 
ing. 60 cc. of sterile distilled water were used and the wash- 
ings passed through a Berkef eld N candle. 

To 10 cc. of washings filtrate were added 2.5 cc. of active 
virus filtrate and the mixture was incubated at 37 °C. for 
24 hours. 1 cc. of the mixture, representing 0.2 cc. of the 
virus filtrate, was injected intracerebrally, under ether an- 
esthesia, into a Macacus rhesus. The monkey remained well. 

35 cc. of the washings filtrate were reduced quickly in 
vacuo at a temperature between 60° and 70 °C. to a volume 
of 5 cc. 1.25 cc. of active virus filtrate were added and the 
mixture was incubated at 37 °C. for 24 hours. 1 cc. of the 
mixture, representing 0.2 cc. of virus filtrate, was injected 
intracerebrally, under ether anesthesia, into a Macacus rhe- 
sus. The monkey was completely paralyzed on the 7th day 
and died on the 8th day. Typical lesions of poliomyelitis 
were present. 

The neutralizing substance is apparently rendered inac- 
tive by heating to 70° C, though this experiment does not 
exclude volatility as the reason for the disappearance of 
this substance. Other experiments, however, in which the 
concentrations were carried out in vacuo at 60° C. indicate 
that the neutralizing substances are not volatile. 



332 INFANTILE PARALYSIS IN VERMONT 

Table V. 
Neutralizing Power of Nasal Washings Heated to 60°C. for 1 Hour 









Temper- 










ature at 










which virus 




Mon- 


Dose 


Fractionally sterilized nasal 


plus nasal 




key 


of virus 
filtrate 


washings from 


washings 
were incu- 
bated for 
2k hrs. 


Result 




cc. 




°C. 




A 


0.4 


W. T., normal adult 


37 


Died in 33 days 


B 


0.4 


<< << << 


4 


(t <( q-J it 


C 


0.4 


G. H., " 


37 


Remained well 


D 


0.4 


<< <( « 


4 


Died in 11 days 


E 


0.4 


C. A. R. (acute rhinitis) 


37 


(< it o <( 


F 


0.4 


<< << <( 


4 


a cc q << 


G 


0.4 


Control (distilled water) 


37 


" " 14 " 



Table VI. 

Neutralizing Power of Nasal Washings Passed through 
a Berkefeld Filter 









Temper- 










ature at 






Dose of 




which virus 




Mon- 


filtrate 


Berkefeld filtered nasal 


plus nasal 




key 


of virus 


washings from 


washings 
were incu- 
bated for 
2k hrs. 


Result 




cc. 




°C. 




H 


0.4 


W. T. normal adult 


37 


Remained well 


I 


0.4 


<< << << 


4 


Died in 16 days 


J 


0.4 


G. H., " 


37 


" " 19 " 


K 


0.4 


(< << << 


4 


Remained well 


L 


0.4 


C. A. R. (4 days after acute 
rhinitis) 


37 


<< <« 


M 


0.4 


C. A. R. (4 days after acute 
rhinitis) 


4 


<< << 



NASAL WASHINGS IN POLIOMYELITIS 
Table VII. 



333 



Effect of Berkefeld Filtration and Heat on the Neutralizing Power 

of Nasal Washings 





Condition of person from 
whom washings were ob- 
tained 


Result of neutralizing test 
against O.k cc. of Berkefeld 
filtrate of virus 


Nasal washings from 


Filtered 
(Berkefeld) 

washings 
plus virus 
allowed to 
remain for 

24 hrs. 


Fractionally 
sterilized 

washings 
(60 °C. on 3 

days) plus 
virus allowed 

to remain 

for 2k hrs. 




37°C. 


4°C. 


37°C. 


4°C. 


W. T., adult 
C. A. R., adult 

G. H., 

Control (distilled water) 


Normal 

Acute rhinitis 

4 days after acute rhinitis 

Normal 


+ * 


+ 
+ 


±t 

+ 


it 



*The sign + indicates neutralization; -1- . marked prolongation of the incubation period preceding 
paralysis. 

flncubation period greatly prolonged. Monkeys developed no symptoms until 33 and 31 days, 
respectively, after inoculation. 

DISCUSSION 

The power of the secretions of the nasopharynx of cer- 
tain but not all individuals to bring about the inactivation 
or neutralization of the active virus of poliomyelitis has 
been demonstrated. The term active is employed to indicate 
that the samples of virus were obtained from Istrains 
adapted to the monkey, and could be relied upon to cause in- 
fection in the doses employed, almost without exception. 

The inactivating property of the secretions mentioned is 
the more surprising in view of the resistance displayed by 
the poliomyelitic virus to such chemical antiseptics as gly- 
cerol and phenol. 

In their manner of action, the neutralizing substances re- 
semble more the specific immunity bodies contained within 
the blood serum of persons and monkeys who have suffered 
an attack of poliomyelitis. Like them, they appear to be 



334 INFANTILE PARALYSIS IN VERMONT 

thermolabile. And yet the experiments here recorded do not 
actually identify the two classes of substances. 

It is known that the blood serum of certain adults who 
apparently have never suffered from poliomyelitis is capa- 
ble of neutralizing 8 the filtered poliomyelitic virus. 9 But in 
the few instances in which this property has been discovered, 
the adults yielding the serum had been in contact with 
acute cases of poliomyelitis, and artificial immunization 
cannot be excluded. 

On the other hand, it seems not improbable that the inac- 
tivating or neutralizing power of the nasal secretions may 
play a part in protection against poliomyelitic infection, and 
even may represent an external system of defense against 
invasion of the virus by way of the nasopharyngeal mucosa. 

If this view is supported by further studies, we should 
find that the secretions of children are less frequently neu- 
tralizing than those of adults, although many tests will be 
necessary to establish this distinction. In that case, we may 
find that the secretions of persons attacked by poliomyelitis 
at the period of onset of the disease lack neutralizing power, 
although later, when the immunization reactions have been 
aroused, inactivation may result, as has been shown to hap- 
pen in particular instances in our series. 

It appears, however, that the power of a given secretion 
to inactivate or neutralize the virus is not wholly a fixed 
one. Fluctuations in the property have been detected and 
described. Common and slight inflammatory conditions, 
e.g., as in acute and even chronic rhinitis, apparently tend 
to remove or diminish the neutralizing power of the secre- 
tions. If this observation should be supported by further 
experiment, knowledge concerning one of the conditions 
favoring persistent contamination of the nasopharynx with 
the virus may be obtained. It does not follow, however, that 

8. Flexner and Lewis, J. Am. Med. Assn., 1910, liv, 1780. 

9. Peabody, F. W., Draper, G., and Dochez, A R., A Clinical Study of Acute Poliomye- 
litis, Monograph of The Rockefeller Institute for Medical Research, No. 4, 1912. 



NASAL WASHINGS IN POLIOMYELITIS 335 

this contamination need necessarily lead to infection, for 
the accomplishment of which disturbance of still other de- 
fensive mechanisms may be necessary. However, the pro- 
duction of healthy carriers of the poliomyelitic virus may 
rest upon the power or lack of power in the secretions to 
inactivate the virus. Should this be the case, then of many 
persons exposed only a fraction would become carriers, be- 
cause the greater part would possess secretions capable of 
neutralizing and hence destroying the virus. 

The variation in inactivating power does not depend 
alone upon inflammatory changes. Irregularities have been 
noted which cannot now be explained. They may be merely 
apparent and depend upon the experimental method to 
which we are at present limited. Inoculation experiments in 
single series are not wholly trustworthy. Filtration through 
porcelain is also open to errors of experiment, since the 
blocking of the porus spaces may easily exclude essential 
constituents of the washings. Fractional sterilization is also 
not a wholly reliable means of preventing bacterial develop- 
ment and yet of retaining unimpaired labile organic con- 
stituents. In view of all this, some degree of irregularity is 
to be looked for. 

If this property of the secretions to inactivate or neutral- 
ize the virus of poliomyelitis is established, comparative 
tests should be made on large groups of persons at different 
seasons of the year in order to determine whether it bears 
any relation to the seasonal prevalence of poliomyelitis. We 
are engaged now in collecting observations covering this 
point ; but reference to the tables will show that most of the 
tests were made during the spring, summer, and autumn. 
Moreover, they embraced few children of the most suscep- 
tible ages. 

SUMMARY 

1. The results of 56 experiments have shown that wash- 
ings of the nasal and pharyngeal mucosas possess definite 



336 INFANTILE PARALYSIS IN VERMONT 

power to inactivate or neutralize the active virus of polio- 
myelitis. 

2. This power is not absolutely fixed, but is subject to 
fluctuation in a given person. Apparently inflammatory 
conditions of the upper air passages tend to remove or di- 
minish the power of neutralization. But irregularities have 
been noted, even in the absence of these conditions. 

3. Too few tests have been made thus far to ascertain 
whether adults and children differ with respect to the exist- 
ence of this neutralizing property in the nasal secretions. 
While the inactivating property was absent from the secre- 
tions of one child during the first days of poliomyelitis, it 
was present in another to whom immune serum was admin- 
istered, and in still another on the 15th day of illness when 
convalescence was established. 

4. The neutralizing substance is water-soluble and ap- 
pears not to be inorganic; it appears to be more or less 
thermolabile, and its action does not depend upon the pres- 
ence of mucin as such. 

5. It is suggested that the production of healthy carriers 
through contamination with the virus of poliomyelitis may 
be determined by the presence or absence of this inactivat- 
ing or neutralizing property in the secretions. Whether this 
effect operates to prevent actual invasion of the virus and 
production of infection can only be conjectured. Probably 
the property is merely accessory and not the essential ele- 
ment on which defense against infection rests. It is more 
probable that other factors exist which help to determine 
the issue of the delicate adjustment between contamination 
and infection. 



CARRIAGE OF THE VIRUS OF POLIOMYELITIS, 

WITH SUBSEQUENT DEVELOPMENT 

OF THE INFECTION* 

By Edward Taylor, M.D. 

and 
Harold L. Amoss, M.D. 

(From the Research Laboratory^ of the Vermont State 
Board of Health, Bvfrlington.) 

THE solution of the problem of the mode of infection 
in poliomyelitis has been attempted in various ways, 
with results which have led to the conclusion that the 
microbic cause is conveyed from one individual to another 
by personal contact. This belief is based upon clinical ob- 
servation and experiment. Wickman first brought clinical 
proof, since supported by many independent observations, 
of the correctness of this generalization; and Flexner and 
Lewis, and later Kling and Pettersson, provided the experi- 
mental demonstration of its adequacy. 

However, a considerable number of physicians and others 
still refuse to accept this explanation. They hold that the 
mode of infection remains undiscovered, or they account for 
it through some variety of insect transmission, also unde- 
tected. In recognition of the skepticism still prevailing, we 
have been led to describe in detail the experimental demon- 
strations of the carriage by healthy persons of the virus of 
poliomyelitis, to which may now be added our own success- 
ful inoculations. Our results include the demonstration, re- 
corded for the first time, that a proved carrier of the virus 

*Reprinted from The Journal of Experimental Medicine, November 1, 1917, Vol. XXVI, 
No. 5, pp. 745-754, 
tMaintained by a special fund privately donated. 

337 



338 INFANTILE PARALYSIS IN VERMONT 

may come down with acute poliomyelitis. This observation 
should serve to strengthen the position of those who accept 
as established the personal communication of the microbic 
cause, or virus, of the disease. 

PREVIOUS REPORTS 

Wickman's 1 clinical studies may be said to have dissemi- 
nated the view of the personal factor in the communication 
of the virus of poliomyelitis. He emphasized the occurrence 
and epidemiological importance of the non-paralytic or ab- 
ortive cases, the first description of which is usually cred- 
ited to him, and of healthy intermediaries, or bacillary car- 
riers, who function as purveyors of the microbic agent. His 
study constituted a great step forward ; but the first person 
to allude to non-paralytic cases of epidemic poliomyelitis is 
Caverly, 2 who records the occurrence of 6 cases among the 
total of 132 cases on which he based his report describing 
the Rutland epidemic of 1894. 

Soon after Landsteiner and Popper's 3 experimental trans- 
mission of poliomyelitis, Flexner and Lewis 4 detected the 
virus in the nasopharyngeal mucous membrane of infected 
monkeys. This observation, soon confirmed by several in- 
dependent bacteriologists, was followed by a study made by 
Kling, Pettersson, and Wernstedt 5 who injected into mon- 
keys buccal washings from so-called abortive cases and 
from healthy contacts. Their results were inconclusive, as 
the clinical condition produced was not typical of poliomye- 
litis, and the pathological changes described as present in 
the spinal cord were not characteristic of the disease. They 
explained the discrepancy by the supposition that the virus 
present in the abortive cases and healthy carriers was rela- 
tively avirulent. This view is repeated in their recent re- 
port 6 in which they describe an instance of healthy carriage 
of the highly active virus inducing paralysis and character- 
istic lesions. The first demonstration of the typical virus in 
the nasopharyngeal washings of healthy persons was, how- 
ever, made by Flexner, Clark, and Fraser, 7 whose report 
follows in detail. 

E. A., female, age 4 years and 4 months. The patient had 
been ill from Oct. 12 to 17, 1912. On the latter date she 
was admitted to the Hospital of The Rockefeller Institute 
for Medical Research, suffering from severe paralytic polio- 
myelitis. She subsequently improved and was discharged, 
Oct. 28. The mother and father of the child were subjected 



CARRIAGE OF THE VIRUS OF POLIOMYELITIS 339 

to a nasopharyngeal irrigation with normal saline solution ; 
about 150 cc. of washings were obtained. The fluid was 
shaken and passed through a Berkef eld filter ; of the nitrate, 
1.5 cc. were injected the same day into the sheath of each 
sciatic nerve and 140 cc. into the peritoneal cavity of a Mac- 
acus cynomolgus (Monkey A). Recovery from the anesthe- 
sia was prompt and the animal remained well until Nov. 11, 
when it was noted to be excited and to drag the right leg; 
the left leg was weak. Nov. 12. Right leg flaccid. A lumbar 
puncture yielded 2.5 cc. of fluid containing excess of white 
corpuscles. Nov. 13. The condition was unchanged; the 
animal was etherized. The organs generally were normal 
in appearance; the spinal cord was edematous. Micro- 
scopic examination of sections of the spinal cord, medulla, 
and interstitial ganglia revealed the characteristic lesions 
of poliomyelitis. The blood vessels and ground substance 
showed infiltrations with mononuclear cells; the motor 
nerve cells were degenerated and invaded by phagocytes. 

Dec. 3. An emulsion of the glycerolated spinal cord and 
medulla was injected into each sciatic nerve and the perito- 
neal cavity of a Macacus cynomolgus (Monkey B) and a 
Macacus rhesus (Monkey C). Dec. 9. The rhesus monkey 
was noted to be excited. Dec. 10. Lumbar puncture yielded 
3 cc. of turbid fluid containing excess of white cells. By Dec. 
13, the legs were partially paralyzed ; the animal was ether- 
ized. Microscopic sections of the spinal cord, medulla, and 
intervertebral ganglia showed typical infiltrative and de- 
generative lesions of poliomyelitis. The cynomolgus monkey 
became excited on Dec. 10, and on the 19th paralysis of the 
legs appeared. By Dec. 21 the arms and back were weak, 
and the paralysis was extending. Dec. 23. The animal was 
etherized. The general viscera appeared normal, but the 
spinal cord was both edematous and congested. The micro- 
scopic sections of the cord, medulla, and intervertebral 
ganglia showed typical infiltrative and degenerative lesions 
attended by neurophagocytosis. Subsequently the glycero- 
lated specimens of the nervous organs of Monkeys B and C 
were used for inoculating still other monkeys, in which typi- 
cal paralysis was induced. 

The conclusion drawn by the authors from this demon- 
strative experiment was to the effect that the parents of 
2 liters from healthy persons in contact with cases of acute 
E. A., neither of whom showed any symptoms of illness and 
who evidently were not suffering from poliomyelitis, har- 
bored the virus of the disease in the nasopharynx. Hence the 



340 INFANTILE PARALYSIS IN VERMONT 

existence of the healthy carrier was thus established ex- 
perimentally. 

The next demonstrative experiment was supplied by 
Kling and Pettersson 6 who, in referring to their earlier 
failure to produce clinically and anatomically typical polio- 
myelitis with nasopharyngeal washings, attribute the fail- 
ure to the injection of insufficient amounts of virus into 
the monkeys. They repeated the tests, using washings con- 
centrated in vacuo with the Faust-Heim apparatus. 

They started out by determining the heat lability of the 
active virus, and ascertained that a liter of fluid carrying an 
effective dose could be evaporated at temperatures ranging 
from 35 to 38° C. to 200 cc. without losing its potency. They 
now obtained nasopharyngeal washings in amounts of 1 to 
poliomyelitis. In one instance in which the washings were 
taken from the healthy members of a family in which one 
member had recently died of acute poliomyelitis, the inocu- 
lation resulted successfully. 

The patient was a male, age 41 years. The illness began 
on Sept. 10, the legs becoming paralyzed 2 days later. Death 
took place on the 4th day of illness from respiratory failure. 
The surviving members of the family consisted of the wife 
and three children, ranging from 10 to 14 years, all remain- 
ing well. One day after the death of the father in a hos- 
pital, nasal washings were taken in distilled water from the 
surviving members of the family. The combined washings, 
amounting to 1 liter, were evaporated in vacuo to 75 cc, 
sodium chloride was added, and the mixture was filtered 
first through paper and then through a Berkef eld candle. 

Sept. 20. 0.5 cc. of the filtrate was injected intracerebral- 
ly and 20 cc. were introduced into the peritoneal cavity of a 
Macacus sinicus. Oct. 2. The right leg and on the next day 
both legs and back were paralyzed, and death resulted. The 
microscopic sections of the spinal cord showed moderate 
perivascular and diffuse infiltration of the nervous tissue 
with mononuclear cells and neurophagocytosis. Oct. 3. A 
second Macacus sinicus was inoculated intracerebrally and 
intraperitoneally with an emulsion of the spinal cord of the 
first animal. On Oct. 13 the right leg and on the next day 
the left leg were paralyzed. Oct. 15. The animal was killed. 
Sections of the spinal cord showed typical infiltrative and 
degenerative lesions of poliomyelitis. 

There can be no doubt, therefore, that in this family one 
or more healthy carriers of the active virus of poliomyelitis 



CARRIAGE OF THE VIRUS OF POLIOMYELITIS 341 

existed. That the result was not due entirely to the employ- 
ment of concentrated washings is indicated by the failure 
to detect the virus in the washings obtained from the healthy 
associates of two other cases of acute poliomyelitis. 

OBSERVATIONS 

In the two successful instances just reviewed, mixed 
washings were employed for inoculation. It is, therefore, 
impossible to state whether one or more of the healthy con- 
tacts of the cases of poliomyelitis were carriers. In the in- 
stance which we shall report the individuals were irrigated 
separately. The final result proved that more than one virus 
carrier was present, and it was demonstrated that such a 
healthy carrier may develop poliomyelitis. We may there- 
fore regard the chain of the mode of infection as now hav- 
ing been completed for the first time. The separate links 
may be defined as follows : 

Case of acute poliomyelitis — ►contact carrier —►second 
case. 

A still further analysis would determine that through the 
contact carrier other carriers occur, among which a certain 
number of additional cases arise. 

Poliomyelitis occurred in epidemic form in Washington 
County, Vermont, in the summer of 1917. From June 1 un- 
til September 1, 79 cases were recognized among the popu- 
lation of 45,000. 

Carey P., male, age 16 years. The patient lived in the 
village of Waitsfield, 18 miles from Montpelier, where cases 
of poliomyelitis existed. No case of the disease had been dis- 
covered in Waitsfield. On June 2, 1917, he attended a ball 
game at Northfield where there were no cases, and return- 
ing home stopped in Montpelier for supper. Probably in 
the assembly at Northfield persons from the infected dis- 
trict were present. Until June 12 there were no symptoms 
of illness ; on that day there was complaint of headache and 
pain in the back and legs. The patient vomited once. June 
13. First seen by a physician who observed that the patient 



342 INFANTILE PARALYSIS IN VERMONT 

had fever, and treated him for a gastrointestinal upset. 
June 16. Extensive paralysis involving both legs, right tri- 
ceps, intercostals, pectorals, and diaphragm. Lumbar punc- 
ture yielded clear fluid under pressure, containing 400 white 
cells per cmm. and excess of globulin. Death occurred on 
this date. 

The family consisted of the father, age 59 years, mother, 
age 42, sister, Hazel, age 13, two brothers, Everett, age 10, 
and Dwight, age 7. The two younger brothers slept in the 
same bed, and in the same room with the elder brother, 
Carey. 

June 16. Everett and Hazel were given nasopharyngeal 
irrigation with distilled water, 60 cc. being obtained from 
the former and 100 cc. from the latter. Ten per cent of ether 
was added to each, and the fluids were sent at once to the 
laboratory. One of us had previously determined that ether 
inhibits bacterial development without injuring the polio- 
myelitic virus. The washings were treated separately as 
follows : Glass beads were added and they were shaken me- 
chanically for 21/2 hours. They were then centrifuged at 
high speed for 2V£ minutes, and the supernatant fluid was 
passed through a Berkefeld N candle and concentrated in 
vacuo by the method already described by us 8 at 35° C. to 
2 cc. The entire concentrate was injected intracerebrally 
into two Macacus rhesus monkeys (Monkey A (Everett) 
and Monkey B. (Hazel) ). The time elapsing between the 
collection and the injection of the washings was less than 6 
hours. 

We return briefly to the history of the two children. 
Everett had not been away from the village and was in 
usual health until June 13, the day after Carey fell ill. He 
also felt indisposed, showed a temperature of 102° F. and 
suffered from diarrhoea, but did not vomit. However, he re- 
covered quickly and subsequently on minute examination 
has shown no muscular weakness or abnormality of reflexes. 

Hazel had not been away from Waitsfield. She had been 



' ■ A 



•.•:: 



; 



-.. 



tf .?* , ■, 



v. 



',• 



.♦ .. 










Fig. 1. Spinal cord of Monkey B, showing perivascular infiltration 
and neurophagocytosis. X 90. 




Carriage of the virus of poliomyelitis.) 

Fig. 2. Medulla of Monkey B, showing diffuse mononuclear infil- 
tration, nerve cell degeneration, and neurophagocytosis. X 230. 







Fig. 3. Intervertebral ganglion of Monkey B, showing infiltrative 
changes and nerve cell invasion. X 120. 





(Taylor and Amoss : Carriage of the virus of poliomyelitis.) 

Fig. 4. Intervertebral ganglion of Monkey B, showing mononuclear 
infiltration, nerve cell degeneration, and neurophagocytosis. X 240. 



CARRIAGE OF THE VIRUS OF POLIOMYELITIS 343 

entirely well at the time the washings were taken and re- 
mained well until June 21, at which time she complained of 
headache. She showed a temperature of 102° F. On June 
22 her reflexes were exaggerated and stiffness of the back 
was present, but no muscular weakness was detected. Lum- 
bar puncture was unsuccessful. The symptoms subsided 
gradually, but reexamination made on July 22 revealed par- 
tial paralysis of the left deltoid, right anterior tibial, and 
abdominal muscles. She had, therefore, suffered a mild 
attack of poliomyelitis. 

Monkey A. — June 16, 1917. Inoculated. Remained well 
until June 29, when it was excitable, emitted staccato cries, 
and showed ruffled hair. The animal was noted to be clumsy 
in movement and unable to jump. June 30. Both legs were 
weak. July 4. The right leg was paralyzed and flaccid ; the 
left leg and back were weak. The paralysis of the left leg 
and back, but not of the right leg, disappeared; the latter 
remained and contracture gradually set in. At the present 
time (Sept. 1) the contraction of the right leg is so marked 
that in moving about the animal does not touch the limb to 
the floor. On Aug. 8 blood was withdrawn for a neutraliza- 
tion test and at the same time an intracerebral inoculation 
was made with a large dose of virus proved active in an- 
other monkey; the result was negative. The animal, as is 
usually the case, having recovered from a recent infection, 
was resistant to reinoculation. 

Monkey B. — June 17, 1917, 3 a.m. Injected intracere- 
brally with 1.5 cc. of the concentrated washings. Recovery 
from the anesthesia was immediate, and the first symptoms, 
consisting of excitability, ruffled hair, staccato cries, and 
partial paralysis of the right leg, were observed. June 26. 
The paralysis being stationary, the animal was etherized. 
The organs appeared normal to the naked eye. Microscopic 
sections revealed, however, marked typical lesions of polio- 
myelitis. They affected the spinal cord (Fig. 1), medulla 
(Fig. 2), and intervertebral ganglia (Figs. 3 and 4), and 
consisted of typical infiltration with mononuclear cells and 
nerve cell degeneration with phagocytosis. 

Monkey C. — June 26, 1917. Injected intracerebrally un- 
der ether anesthesia with 2.5 cc. of a 20 per cent emulsion 
of spinal cord and medulla of Monkey B. July 7. The first 
symptoms were noted, consisting of ruffled hair and inclina- 



344 INFANTILE PARALYSIS IN VERMONT 

tion of head to the left. July 8. The animal was ataxic and 
protected the right leg. July 9. Unable to jump; legs and 
back weak. July 10. Paralysis progressing. July 15. Ether- 
ized. The spinal cord showed typical focal lesions of polio- 
myelitis in which cicatrization was beginning. 

These experiments leave no doubt that the washings, both 
from Everett and from Hazel, contained the virus of polio- 
myelitis. The instance of Hazel is of particular importance 
since in her case the virus was detected in washings taken 
5 days before the first symptoms of what proved subse- 
quently to be a mild attack of poliomyelitis set in. In other 
words, she was carrying the virus in her nasopharynx sev- 
eral days in advance of the appearance of any signs of ill- 
ness. She constitutes, therefore, an example of a carrier of 
the virus developing poliomyelitis — the first one in which 
the demonstration has been proved experimentally. 

The interpretation in the case of Everett is not so simple. 
When the virus was detected in his nasopharynx he had 
passed through a slight attack of illness, at about the same 
time with, and of about the same character as that of his 
brother Carey who died, but unattended by paralysis. The 
presumption is that Everett suffered from a non-paralytic 
or abortive attack of poliomyelitis. The detection of the 
virus in his case proves him not to have been a healthy, 
but a recovered carrier of the microbic cause of the disease. 

The two children having been shown to be virus carriers, 
their nasopharyngeal secretions were tested by the method 
of Amoss and Taylor, 8 to determine whether they would 
neutralize an active poliomyelitic virus. 

July 23, 1917. Washings with sterile water were taken 
from the children, and fractionally sterilized and mixed. To 
15 cc. of the mixture were added 3.75 cc. of a Berkefeld fil- 
trate of a 5 per cent stock glycerolated poliomyelitic spinal 
cord. After shaking, the combined fluids were permitted to 
remain at 37° C. for 24 hours. 1 cc. of the fluid was injected 
intracerebrally into a Macacus rhesus. No symptoms ap- 



CARRIAGE OF THE VIRUS OF POLIOMYELITIS 345 

peared until Aug. 4, when excitability, ataxia, paralysis of 
the right arm, and weakness of the back were noted. Aug. 
8. Animal prostrate. Aug. 10. Died. The microscopic le- 
sions were typical of poliomyelitis. 

The mixed nasal washings failed, in this experiment, to 
neutralize the virus. 

The youngest child, Dwight, age 7 years, was refractory 
and no washings were obtained from him on June 16 when 
they were taken from the other children. On June 18 he 
complained of being unwell. The symptoms were severe 
headache, stiffness of neck, exaggerated reflexes, but no 
diarrhoea. Lumbar puncture yielded a fluid containing 500 
white cells per cmm. and an excess of globulin. Immune 
poliomyelitic serum from recovered cases of the disease was 
administered intraspinally, intravenously, and subcutane- 
ously : 24 cc. were given intraspinally, 30 cc. intravenously, 
and 39 cc. subcutaneously. Recovery was prompt, with a 
slight paralysis of the right anterior tibial muscle. Naso- 
pharyngeal washings were, however, obtained on Septem- 
ber 4, which after filtration and concentration were inocu- 
lated into a Macacus rhesus (Monkey D). The monkey 
remained well. 

DISCUSSION 

This series of cases of poliomyelitis in one family, with 
the circumstances surrounding their origin, forms an in- 
structive illustration of the mode of infection of the disease 
as brought out by the clinical and experimental study. 

In the first place, one child only — the eldest boy, Carey — 
was exposed in a locality in which poliomyelitis was epi- 
demic. The exposure took place on June 2. Immediately 
afterwards he returned home, to a village in which no previ- 
ous case of the disease had occurred, and mingled freely 
with his younger brothers and sister. The contacts may be 
considered to have been intimate in that the three male chil- 
dren slept in the same room, two of them in the same bed. 



346 INFANTILE PARALYSIS IN VERMONT 

The incubation period in Carey's case was 9 or 10 days, 
as he was taken ill on June 12. His brother Everett, 6 
years younger, developed symptoms 1 day later and passed 
through what was probably a non-paralytic attack of polio- 
myelitis. He may be considered as having been infected by 
Carey some time during the incubation period, and to have 
exhibited a shorter incubation than his brother. The young- 
est brother, Dwight, was also freely exposed to both older 
brothers and exhibited symptoms passing into those indica- 
tive of poliomyelitis 5 or 6 days later than his brothers. 
Finally, Hazel, the sister, in age between the two older 
brothers and possibly less freely exposed, developed symp- 
toms and muscular weakness last of all and about 10 days 
after the eldest brother. The incubation periods of the cases, 
therefore, probably were 10 days or less, and the order of 
the attacks was such as to indicate successive infection and 
not a common one. 

The second feature worthy of emphasis is the detection 
in this one family of two carriers of the poliomyelitic virus 
by the inoculation test. One (Everett) was discovered to 
be a carrier probably following a non-paralytic attack. In 
the instance of Hazel there is no doubt, first that she was 
discovered to be a healthy carrier, and second that she de- 
veloped typical poliomyelitis during the period of carriage. 
Incidentally the nasopharyngeal secretions of Hazel and 
Everett failed to neutralize the poliomyelitic virus. 

If the view that the mode of infection in epidemic polio- 
myelitis is by way of the nasopharyngeal mucous membrane 
and is brought about or greatly facilitated through the oper- 
ation of healthy carriers of the virus is accepted, we may 
well consider whether in the final analysis every case of the 
disease does not develop from a carrier. At first this may 
seem startling, and yet it merely means that after contami- 
nation of the nasopharynx with the virus, an intervening 
period exists during which persistence, multiplication, and 



CARRIAGE OF THE VIRUS OF POLIOMYELITIS 347 

invasion of the virus take place. In not all contaminated 
persons does this process become complete; in some the 
virus may merely persist for a time, in others it may mul- 
tiply in the nasopharynx (these constitute the healthy car- 
riers of greater or less endurance), while in the exceptional 
few invasion also occurs. In the last class symptoms arise, 
and these individuals become cases of poliomyelitis. 

SUMMARY 

A family group containing four children of whom all 
showed in varying degree symptoms of poliomyelitis is de- 
scribed. The source of infection and periods of incubation 
have been followed. Two of the children were proven by in- 
oculation tests to carry the virus of poliomyelitis in the na- 
sopharynx. Of these, one was detected to be a carrier after 
recovering from a non-paralytic attack of the disease, and 
the other was discovered to be a carrier about 5 days before 
the initial symptoms, attended later by paralysis appeared. 
The original case from which the three others took origin 
was fatal; the youngest child, after quite a severe onset, 
was treated with immune serum, and made a prompt and 
almost perfect recovery. The nasopharyngeal secretions of 
two of the cases, taken 1 month after the attack, proved in- 
capable of neutralizing an active poliomyelitic virus. 

The proposition is presented that every case of polio- 
myelitis develops from a carrier of the microbic cause, or 
virus, of poliomyelitis. 

1. Wickman, I., Beitrage zur Kenntnis der Heine-Medinschen Krankheit. Berlin, 1907. 

2. In view of the importance which 1 the non-paralytic cases have assumed in the epi- 
demiology of poliomyelitis it is pertinent to quote Oaverly, who states that paralysis oc- 
curred in 119 cases, 7 cases died before paralysis was detected, "and the remaining 6 had 
no paralysis, but all had a group of symptoms very common in the initial stage in those 
which were paralyzed, such as headache, fever, convulsions, or nausea, one or all" (J. 
Am. Med. Assn., 1896, xxvi, 1). 

3. Landsteiner, K., and Popper, E., Z. Immunitatsforsch., Orig., 1909, ii. 377. 

4. Flexner, S., and Lewis, P. A., J. Am. Med. Assn., 1910, liv, 1140. 

5. Kling, C, Pettersson, A., and Wernstedt, W., Communications Inst. med. Etat a 
Stockholm, 1912, iii, 5. 

6. Kling, C, and Pettersson, A., Deutsch. med. Woch., 1914, xl, 320. 

7. Flexner, S., Clark, P. F., and Fraser, F. R., J. Am. Med. Assn., 1913, Ix, 201. 

8. Amoss, H. L., and Taylor, E., J. Exp. Med., 1917, xxv, 507. 



THE TREATMENT OF ACUTE 
POLIOMYELITIS! 

Preliminary Note on Use of Hypertonic Salt Solution 
and Convalescent Human Serum* 

William Lloyd Aycock, M.D. 

and 

Harold L. Amoss, M.D. 

THE results in general of the serum treatment of acute 
poliomyelitis have not been sufficiently consistent to 
warrant a definite statement as to its value. In the 
absence of hyperimmune serum, recourse must be had to 
human convalescent serum, which is at best weak in its 
antibody content. In a small series, 1 the administration of 
large doses of convalescent serum a few hours after onset 
yielded distinctly encouraging results, but it is agreed that 
the problem has not been solved. Such treatment is beset 
with obstacles apparently insurmountable, one of the great- 
est of which is the inaccessibility of the site of injury in 
poliomyelitic infection. 

Since the flow of fluid within the nervous tissue itself 
is probably from the capillaries along the pericapillary, 
perineuronal and perivascular spaces toward the subarach- 
noid space, serum injected merely into the subarachnoid sac 
cannot be expected to reach the inflammatory focus lying 
deep in the gray matter of the cord. It is likewise true that 
the walls of the capillaries of the nervous tissue constitute 
an effective barrier against the passage of serum from the 



fCopyright, 1923, Am. Med. Assn. Reprinted by permission from J. of A. M. A., Aug. 
11, 1923, Vol. 81. 

* From the Research Laboratory (maintained by a special fund privately donated), 
Burlington, Vt., and the Biological Division of the Medical Clinic, Johns Hopkins Hos- 
pital and University. 

1. Amoss, H. L., and Chesney, A. M. : J. Exper. Med. 25: 581 (April) 1917. 

348 



THE TREATMENT OF ACUTE POLIOMYELITIS 349 

circulation to the perivascular system. 2 Weed and his co- 
workers 3 have shown that the intravenous injection of 
hypertonic solutions in normal animals causes a reduction 
in the volume of the brain and spinal cord with a marked 
lowering of the cerebrospinal fluid pressure and an aspira- 
tion of fluid from the subarachnoid space into the perivas- 
cular "lymph" spaces of the brain and cord. 

In our experiments, 4 similar results have been obtained 
in the edematous cords of monkeys in the acute stage of 
poliomyelitis, and have led to the employment of the method 
in the treatment of the experimental disease. Poliomyelitic 
monkeys given convalescent human serum intraspinally and 
intravenously, and hypertonic salt solution intravenously, 
exhibited marked improvement as compared to controls. 
By the shrinking of the central nervous tissues after intra- 
venous injection of hypertonic salt solution, more space is 
available in the subarachnoid space for the reception of 
large amounts of serum; this is especially advantageous, 
since the convalescent serum is at best weak in antibody 
content, and correspondingly larger amounts must be in- 
jected. The beneficent effect of the change in tonicity of the 
blood, with the marked decrease in the volume of the brain 
and spinal cord, is to reduce the inflammatory edema of the 
cord. However, it seems that edema cannot be explained 
entirely on the basis of osmosis. Our experiments have not 
progressed sufficiently to warrant any statement on this 
point. 

The third and probably the main possibility of a benefi- 
cent effect of such a method lies in the fact that the intra- 
venous injection of hypertonic solution brings about an as- 
piration of serum from the subarachnoid space into the 

2. Mott, F. W. : Lancet 2 : 79, 1910. Flexner, Simon : The Local Specific Therapy of 
Infections, J. A. M. A. 61 : 447 (Aug. 16) 1913. Flexner, Simon, and Amoss, H. L. : 
J. Exper. Med. 25: 499 (April) 1917 

3 Weed, L. H. : J. M. Res. N. S. 26: 93, 1914. Weed, L. H., and Hughson, Walter: 
Am. J. Physiol. 58: 53, 101 (Nov.) 1921. Weed, L. H., and McKibben, P. S. : Ibid. 
48: 531, 1919. Weed, L. H. : Am. J. Anat. 31: 191 (Jan.) 1923. 

4. These will be reported in the Bulletin of the Johns Hopkins Hospital, December, 1923. 



350 INFANTILE PARALYSIS IN VERMONT 

perivascular system, thus insuring a more intimate contact 
between the main lesions of poliomyelitis and the serum, 
which can be regarded as a distinct advantage in local spe- 
cific therapy. There is one other possibility in connection 
with the employment of this method. It is possible to admin- 
ister enough hypertonic solution, approximately 1 gm. of 
sodium chloride per kilogram of body weight, to cause cere- 
brospinal fluid pressure to fall from 80-120 mm. of water 
to — 90 mm. of water without damage. This loss of fluid 
within the central nervous system is replaced afterward by 
an increased passage of fluid from the blood stream to the 
cerebrospinal fluid, normal pressure being reestablished 
within a few hours. On the hypothesis that this increased 
flow of fluid would facilitate the passage of serum from the 
circulation to the fluid spaces of the central nervous tissue, 
the intravenous injection of immune serum one or two 
hours after the injection of hypertonic solution is recom- 
mended. 

REPORT OF CASE 

Opportunity for the application of this method to cases 
in human beings has not yet been afforded except in one in- 
stance. It is realized that, without data from many cases, 
no conclusions can be drawn ; yet, owing to the demand for 
details of the method a brief report of one case is given. 

History. — G. E. I., a boy, aged 4 years, with normal de- 
velopment, and past history unimportant, entered Harriet 
Lane Home 5 of the Johns Hopkins Hospital, Jan. 16, 1923, 
for treatment for acute abdominal pain and sudden loss of 
power to move the arms and legs, closely following a gastro- 
intestinal upset. The onset occurred January 8, with re- 
peated chills and fever, which endured for two days. On the 
fourth day, the symptoms disappeared, and the patient re- 
mained asymptomatic until the morning of January 15, 
when he told his mother that he could not "wiggle his toes." 
The weakness of the legs noticed at that time gradually in- 

5. The patient was under the care of Dr. W. J. Scott, from whose notes this abstract 
was taken. 



THE TREATMENT OF ACUTE POLIOMYELITIS 351 

creased until motion was lost. Tingling in the fingers ap- 
peared, and there was a rapid loss of motor function of the 
arms and trunk. On admission, the temperature was 100.4 
F., the respirations, 40, and the pulse, 120. The patient was 
mentally clear and cooperative. The extremities were flac- 
cid, with perhaps slight power in the right arm and leg. The 
patient was unable to move in bed. Speech was normal. 

Examination. — The head, eyes, ears, sinuses, nose, throat 
and mouth were normal. There was no glandular enlarge- 
ment ; the chest, heart, lungs, abdomen, genitalia and joints 
were normal. The extremities were flaccid, as already de- 
scribed. 

The tendon reflexes of the upper and lower extremities 
could not be obtained; the abdominal reflexes were hyper- 
active. There was no clonus, and no Babinski's sign on 
either side; Kernig's sign was negative. There was no ab- 
normality of the cranial nerves, and no disturbances of sen- 
sation. Flexion of the neck and back produced pain. 

Urine examination was negative. Blood examination re- 
vealed: red blood cells, 5,288,000 (cells normal) ; white 
blood cells, 19,500. Spinal fluid withdrawn at 7:30 p. m., 
January 16, was clear and under normal tension ; there were 
40 cells, mostly mononuclear, and the globulin test was neg- 
ative; the Wassermann reaction was negative. An intra- 
cutaneous injection of 0.1 mg. of tuberculin gave a positive 
reaction. A roentgenogram of the chest showed no abnor- 
mality. 

Course and Treatment. — At noon, January 17, it was no- 
ticed that the facial muscles on the right side, and inter- 
costal muscles on both sides were weak. Both anterior and 
posterior deltoid muscles on the left side were completely 
paralyzed, and all the muscles of the right arm were weaker 
than normal. The right leg was now completely paralyzed. 

It seemed entirely reasonable to suppose that this was a 
case of acute poliomyelitis of Landry's type, and the subse- 
quent course substantiates this view. 

On the basis of results obtained in the treatment of ex- 
perimental poliomyelitis in monkeys, treatment with intra- 
venous hypertonic solution and convalescent human serum 
was begun. 

January 17, at 8 p. m., lumbar puncture was performed ; 
35 cc. of clear spinal fluid was removed, and human con- 
valescent poliomyelitic serum allowed to flow in until equi- 
librium was established with a head of 4 inches. It was 
estimated that 20 cc. of serum flowed into the subarachnoid 
space. While the needle and connections remained in place, 



352 INFANTILE PARALYSIS IN VERMONT 

there was injected, intravenously under ether anesthesia, 
25 c.c. of concentrated Ringer's solution, of which the sodi- 
um chloride content was 18 per cent. Within two minutes, 
the serum began to flow again into the spinal canal at a 
fairly rapid rate. After 20 c.c. of serum had been allowed 
to flow in, there was no apparent decrease in the rate of 
flow, and the needle was withdrawn. Since there was al- 
ready obvious involvement of the respiratory center, the 
injections were made with dispatch, and no manometric 
readings were made. 

During the night, the patient was very thirsty; a small 
amount of crushed ice was allowed, but water was withheld. 
By 1 o'clock that night, the rectal temperature reached 
104.4. There were two short convulsions and convulsive 
movements of the back muscles. Fluids were given by 
mouth, and the temperature was reduced to 102. The patient 
was very restless. 

January 18, at 10 a. m., lumbar puncture was again per- 
formed. The fluid obtained was turbid, with 18,000 cells 
per cubic millimeter, most of them polymorphonuclear. The 
temperature became normal at 7 p. m. The white blood cell 
count was 25,000. At 10 p. m., the diaphragm was weaker, 
and the abdominal muscles were being used more than 
usual. 

January 19, at 9 a.m., the patient seemed better. Five per 
cent glucose solution by rectum was not retained. Fluids 
were given by mouth in small amounts. The patient could 
swallow, but seemed unable to cough. The chest was clear, 
and the respiratory rate was from 26 to 30 a minute. 

January 20, respirations were improved, and the patient 
seemed brighter. He complained at times of pains in the 
legs. 

January 21, the patient seemed very bright, and the fa- 
cial weakness had almost disappeared. 

January 22, he was breathing with less difficulty. There 
were four loose, involuntary stools. 

January 23, there were no more involuntary stools, and 
the patient voided normally. He was hungry for the first 
time. Breathing was improved, but there was still a notice- 
able weakness of the diaphragm. 

January 25, there was a return of the inability to move 
the fingers and toes. 

January 27, there was improvement in the muscles of the 
shoulder. 

January 28, the muscles of the arm were stronger. 

January 30, the patient moved the fingers of both hands 



THE TREATMENT OF ACUTE POLIOMYELITIS 353 

for the first time, the right better than the left. Neither 
thumb functioned. The triceps muscle on the right func- 
tioned. The left arm was flaccid, but could be moved slight- 
ly with effort. There was slight power in the right biceps, 
and none in the left. 

February 1, there was slight voluntary contraction of 
both adductors. 

February 3, the diaphragm and intercostal muscles were 
definitely stronger. 

February 4, there was a slight return of power in the left 
triceps muscle; the right was stronger. 

February 10, there was definite improvement of the mus- 
cles previously mentioned. 

February 23, there were movements in the right leg. 

The patient continued to improve, and was discharged, 
March 29. Monthly observations have revealed a steady im- 
provement and excellent restoration of function of the mus- 
cles of the upper extremities. The patient was seen last, 
June 14. At that time there was still some weakness of grip 
in the left hand, and slight weakness of the posterior deltoid 
on the right, but he was able to raise both arms above his 
head, to flex his thighs on his abdomen, turn over in bed 
and sit up. There was slight motion in the toes of the right 
foot — none in the left. 

COMMENT AND SUMMARY 

The story, taken as a whole, conforms well to the type of 
Landry's paralysis seen in epidemics, but unusual in spo- 
radic cases of poliomyelitis. In such a case presenting first 
paralysis of the extremities rapidly extending and finally 
developing respiratory paralysis, the prognosis was very 
grave, and it was because of the apparent hopeless outlook 
that a method of treatment not yet fully developed and 
hitherto employed only in experimental poliomyelitis was 
applied. 

Whether the intravenous injection of hypertonic salt so- 
lution stayed or slightly cleared the edema of the cord, or 
brought the convalescent human serum nearer the site of 
the inflammation, or only made it possible to inject more 
serum intraspinally without danger of pressure, is not yet 
clear. 



354 INFANTILE PARALYSIS IN VERMONT 

This case is described in order to present details of the 
method of the treatment, and no claim whatever is made 
that the patient was benefited by the injections. Apparently 
no harm was done by the procedure. 

On account of the limited amount of serum on hand, the 
intravenous injection of 100 c.c. of convalescent human 
serum after the administration of hypertonic salt solution 
was omitted. This plan is recommended on the basis of ex- 
periments to be described in a forthcoming paper. In these 
experiments, it was found that, while no especial difficulty 
was encountered in initial injections of hypertonic solu- 
tions, daily repetition of the injection in poliomyelitic mon- 
keys caused respiratory failure sometimes after compara- 
tively small amounts of hypertonic solution had been in- 
jected. Hence, repeated injections cannot be recommended. 

We are indebted to Dr. John Howland for permission to 
study and report this case. 



EXPERIMENTS ON LOCAL SPECIFIC 
THERAPY IN POLIOMYELITIS* 

The Utilization of Hypertonic Solutions in the Serum 
Treatment of Experimental Poliomyelitis 

By W. L. Aycock, M.D. 

AND 

H. L. Amoss, M.D. 

(From the Research Laboratory^ of the Vermont State 
Board of Health, Burlington, and the Biological Divi- 
sion of the Medical Clinic, Johns Hopkins University 

and Hospital) 

THE blood sera of human beings who have recovered 
from an attack of poliomyelitis and of monkeys (Mac- 
acus rhesus) which have recovered from the experi- 
mental disease are known to contain antibodies active 
against the virus, 2 ' 7 ' 16 but the production of an artificial im- 
mune serum (hyper-immune) has not yet been accom- 
plished. Favorable results have been obtained by the use 
of blood serum from human convalescents in the treatment 
of the experimental infection in monkeys 17 ' 18 and of the dis- 
ease in human beings. 15 ' 19 ' 20 ' 21 However, these results have 
fallen short of the expectations which the demonstrated 
immunological properties of this serum would seem to war- 
rant. The methods heretofore employed in the serum treat- 
ment of this disease have been chiefly intravenous and in- 
traspinous injections, but a consideration of the modern 
conception of the circulation of the fluids of the central 
nervous system tissues raises the question as to whether 

*Reprinted from Johns Hopkins Hospital Bulletin, Nov., 1923. 
tMaintained by a special fund privately donated. 

35S 



356 INFANTILE PARALYSIS IN VERMONT 

or not these methods of administration provide the optimal 
conditions for the therapeutic action of the serum. Since 
human immune serum can be obtained only in limited quan- 
tity and on account of the fact that it cannot be expected, 
by reason of its low potency, to yield the results which 
might be obtained with an hyper-immune serum, it is im- 
portant that, pending the development of a more efficacious 
serum, every effort be made to obtain the maximal effect 
of this serum. Recent advances in the knowledge of the 
circulation of fluids of the central nervous system and the 
experimental production of alterations of these fluid cur- 
rents suggest possibilities in this connection, and form the 
basis of the experiments to be recorded here. 

MECHANISM OF LOCAL SPECIFIC THERAPY 

Effective local specific therapy in disease of parasitic ori- 
gin may be accomplished where it is possible to cause a suit- 
able chemical or biologic agent to act on the parasites in a 
sufficient degree of concentration and for such a period of 
time as is necessary to accomplish their destruction with- 
out, of course, causing undue injury to the tissues of the 
host. 32 ' 37 It has been shown, for example, that the higher 
the concentration of the specific curative agent about the 
parasites in trypanosomal, meningococcal, and other infec- 
tions, the greater is the assurance of their complete destruc- 
tion. The availability of any remedial agent introduced into 
the body for this purpose is determined by its distribution 
there, and this in turn is dependent upon (a) the ability of 
a substance when introduced into one portion of the body 
to be carried by its physical or chemical affinities to other 
portions which harbor the micro-organisms, or (b) the 
ability to introduce the substance directly into the focus of 
the infection. There are excellent instances of the fortu- 
nate combination of circumstances which permit the utili- 
zation of each of these mechanisms for obtaining the de- 



LOCAL SPECIFIC THERAPY IN POLIOMYELITIS 357 

sired distribution of remedial agents. For example, tetanus 
antitoxin introduced into the subcutis for prophylactic pur- 
poses is carried to other points at which its action is desired 
in sufficient amount to bring about the neutralization of the 
toxin as it is liberated at the seat of the infection ; whereas 
the fact that one is able to introduce antimeningococcic 
serum directly into the subarachnoid space makes possible a 
therapy of a degree of effectiveness which could not be 
brought to bear upon this disease if it were possible to in- 
troduce the serum into the circulation only, for example, 
and to rely upon its affinities for tissues to reach the lesions 
within the meninges. 

In other instances the circumstances are not so fortunate. 
By reason of the fact that the parasites are so situated 
within the body that they do not lie within the paths of 
distribution of the particular therapeutic agent which are 
the result of its affinities for certain tissues, or if the para- 
sites lie in a region of the body into which the curative 
agent may not be introduced directly, then either of the 
mechanisms referred to becomes ineffective. This is espe- 
cially true of the tissues of the central nervous system. It is 
a striking fact that therapy in diseases in which the para- 
sites exist within the central nervous system tissue is la- 
mentably ineffective despite the fact that the chemicals or 
sera employed, as evidenced by tests against the micro- 
organisms concerned, are suitable for their complete de- 
struction. That this failure, at least in some instances, is 
due to the inability of the medication to reach the parasites 
is amply shown by the fact that lesions in more accessible 
portions of the body caused by the same organisms respond 
readily to such remedies, as, for example, in the case of 
syphilis of other tissues as compared with syphilis of the 
central nervous system. 

The virus of poliomyelitis has not been found in the blood 
or cerebrospinal fluid at any stage of the disease in human 



358 INFANTILE PARALYSIS IN VERMONT 

beings. 6 ' 36 In certain experiments on the route of infection, 
in which the monkey was used as a test animal, the virus 
was detected in the cerebrospinal fluid soon after its injec- 
tion intravenously and in other experiments after its appli- 
cation to the nasal mucosa. However, after intravenous in- 
jection it tends to disappear from the blood stream so that 
after 120 hours it can no longer be detected there, 35 and 
although the virus was present in the cerebrospinal fluid 
on the third day after intracerebral inoculation, 9 it was not 
demonstrable in it after the onset of symptoms of the ex- 
perimental disease in the monkey. 4 Thus, any appearance 
of the virus in the blood or in the cerebrospinal fluid is 
transitory and may be regarded as representing a stage in 
its passage from the exterior to the central nervous system 
tissue. Once localized in the central nervous system tissue, 
it does not again appear in the blood or cerebrospinal fluid 
during the course of the infection. Hence it would appear 
that the introduction of immune serum into either one of 
these fluids does not of itself insure contact of the immune 
serum with the invading virus. 

INTRAVENOUS SERUM TREATMENT 

Any substance in order to be delivered to the tissue cells 
from the circulation must pass through the walls of the 
capillaries. This endothelial wall exercises a high degree 
of specificity in regard to the substances which it allows to 
pass. This discriminatory power of the capillaries varies 
in different portions of the body in accordance with the 
needs of the particular tissues concerned, and in the case of 
the capillaries of the central nervous system, namely, the 
vessels of the brain and spinal cord and the specialized 
choroid plexus, it reaches a high degree of perfection. 33 
These vessels are known to be capable of excluding most 
substances, including immunity principles, which may be 
present in the blood, from the tissue of the central nervous 



LOCAL SPECIFIC THERAPY IN POLIOMYELITIS 359 

system. 34 The cerebrospinal fluid is derived from the blood 
stream through the medium of these capillary systems and 
the character of this fluid itself is evidence of the precision 
of the apparatus which secretes it. These considerations in- 
dicate that immune serum introduced into the circulation 
would be entirely excluded from the tissue spaces of the 
central nervous system and this seems to be the case, pro- 
vided the capillary walls which guard the entrance to these 
tissue spaces are intact. However, certain changes occur, 
or may be induced, which alter the permeability of these 
vessels and these should be taken into consideration if a 
proper understanding of the action of intravenous injection 
upon the central nervous system is to be arrived at. 

Flexner and Amoss 8 found that an irritation or even a 
slight alteration in the integrity of the meninges or choroid 
plexus, resulting from the subarchnoid injection of normal 
horse serum or other substances, permits the virus of polio- 
myelitis, when introduced into the circulation, to pass to 
the central nervous tissue and set up infection. Moreover, 
they demonstrated that immunity principles, although pres- 
ent in the blood as early as the sixth day of the disease, 17 
pass to the cerebrospinal fluid with difficulty, 3 and suggest 
that the inflammatory condition present in the meninges 
might account for this passage of immunity principles from 
the blood to the cerebrospinal fluid and thus comprise a 
fortunate element in the pathological events of the disease. 
Flexner and Amoss have also shown that immunity princi- 
ples, when injected into the blood stream, can be made to 
pass to the cerebrospinal fluid under conditions in which 
the meninges have been experimentally inflamed. 3 Nu- 
merous observations of a similar nature have been re- 
corded 27 ' 28 ' 29 ' 30 in respect to the passage of other substances 
from the circulation to the cerebrospinal fluid, and form the 
basis of the clinical application of an artificial disturbance 
of the relation between the blood stream and the cerebro- 



360 INFANTILE PARALYSIS IN VERMONT 

spinal fluid spaces in the treatment of certain disease of the 
central nervous system. 

The term "permeability of the meninges" has come into 
rather common use in reference to the passage of sub- 
stances from the blood stream to the cerebrospinal fluid, 
but the exact manner in which such passage takes place is 
not yet known. 

The fluid of the subarachnoid spaces is the combined 
product of the choroid plexus and the capillaries within the 
central nervous tissue itself. 31 These structures, as well as 
the capillaries of the meninges and the posterior root gang- 
lia, 22 have been suggested as possible points of entrance in- 
to the central nervous tissue for substances coming from the 
circulation under the influence of a disturbance which brings 
about what is called an increased permeability of the men- 
inges ; and since fluid derived from each of these structures 
follows a different course within the central nervous system, 
it is to be expected that a substance delivered to the central 
nervous tissue from the circulation would depend for its 
distribution there upon whether it comes through one or 
another of these pathways. The criteria for affirming the 
passage from the circulation to the nervous tissue are the 
setting up of infection within the nervous system or the 
demonstration of the test substance in the cerebrospinal 
fluid, but in neither case may it be said with certainty 
through which gateway it has passed, and therefore the 
pathway which it has traversed within the central nervous 
system remains in doubt. While it is true in the case of 
infection with the virus of poliomyelitis that the process 
may be found within the nervous tissue itself, it does not 
follow that the infective agent was deposited there by the 
capillaries of that region, for indeed it has been shown that 
lesions are always present in the meninges 5 even very early 
in the disease, and that intraspinal inoculation causes in- 
fection, although the virus disappears rapidly from the sub- 



LOCAL SPECIFIC THERAPY IN POLIOMYELITIS 361 

arachnoid space. 5 ' 36 Thus, by extension (multiplication of 
the virus) it reaches the tisue spaces within the brain and 
cord. In the case of the appearance, of test substances in 
the cerebrospinal fluid, it is to be recalled that the fluid as 
obtained by lumbar puncture represents the combined prod- 
uct of the choroid plexus and the perivascular system ; hence 
the presence of a substance in this fluid gives no indication 
as to which one of the pathways it has traversed. Nor can 
it be supposed that a substance dissolved in cerebrospinal 
fluid would enter the substance of the central nervous sys- 
tem in a manner similar to that which may take place in the 
case of a multiplying virus. 

The fluid elaborated by the choroid plexus into the lateral 
ventricles of the brain flows through the foramen of Monro 
to the third ventricle, then to the fourth ventricle and 
through the foramina of Magendie and Luschka to the sub- 
arachnoid space, from which it is finally drained into the 
dural sinuses through arachnoid villi and to a certain extent 
along the sheaths of cranial and spinal nerves, finally to 
be taken into lymphatic channels. Thus it would appear 
that that portion of the cerebrospinal fluid coming from the 
choroid plexus is never brought into intimate contact with 
the central nervous tissue itself but remains without the 
boundaries of the nervous structure, namely, the pia mater 
and the ependymal lining of the ventricular system. It fol- 
lows, then, that immune serum coming from the circulation 
along with this fluid would have little chance of being 
brought into contact with poliomyelitic lesions within cen- 
tral nervous tissue. 

In like manner any fluid discharged from the capillaries 
of the meninges would pass immediately to the fluid in the 
subarachnoid space to be carried away along with the fluid 
from the choroid plexus. 

There remains to be considered that portion of the cere- 
brospinal fluid which is elaborated by the capillaries within 



362 INFANTILE PARALYSIS IN VERMONT 

the nervous tissue itself. This fluid passes through the 
walls of capillaries and circulates within the perivascular- 
perineuronal system, carrying nutritive substance to, and 
removing waste products from the cells, and finally dis- 
charging into the subarachnoid space and becoming a part 
of the common cerebrospinal fluid. It is this fluid alone 
which bathes the cells of the central nervous tissue, and 
only through it can it be expected that immune serum would 
reach the cells of the nervous structure from the circulation. 
In order for such a passage of immunity principles to take 
place it would be necessary that the integrity of this capil- 
lary system be altered. As has been pointed out, the exact 
mechanism of the changes which permit the passage of im- 
mune bodies from the circulation to the cerebrospinal fluid 
involves especially the blood vessels of the meninges and 
then the choroid plexus. Involvement of the capillaries 
within the nervous tissue has not been demonstrated in 
this connection, and from the location of these capillaries in 
reference to the meningeal surfaces such an assumption is 
hardly justified, so that it may be considered highly im- 
probable that these capillary walls are the gateway through 
which substances pass. 

With these considerations in mind the statement may be 
made that the intravenous administration of immune serum 
for the treatment of acute poliomyelitis is beset with the 
following difficulties: 

(a) The great dilution of the serum in the circulation 
renders only a small proportion of it available for passage 
to the site of the lesions. 

(b) The barrier between the circulating blood and the 
central nervous tissue, the capillaries of the central nervous 
tissue itself, choroid plexus and meningeal blood vessels 
would tend to reduce still further the proportion of serum 
which gains entrance to the central nervous tissue. 

(c) Given the conditions under which immunity sub- 



LOCAL SPECIFIC THERAPY IN POLIOMYELITIS 363 

stances are permitted to enter the cerebrospinal fluid from 
the circulation, it is still, on account of the particular por- 
tion of the barrier which is broken down by the means at 
hand and the distribution within the central nervous system 
that which it permits, highly improbable that they are 
brought into contact with the main lesions of acute polio- 
myelitis. In this connection it should be stated that, although 
the vessels of the nervous tissue are involved in poliomye- 
litis, no increase in their permeability has been demon- 
strated. 

INTRASPINAL SERUM TREATMENT 

It has been shown by Weed 31 that true solutions intro- 
duced into the subarachnoid space fail to enter the peri- 
vascular system of the central nervous tissues but join the 
current of the fluid contained in this space which is, as was 
pointed out in a previous paragraph, over the surfaces of 
the meninges and toward the exits from the central nervous 
system into dural sinuses. Clinically, the reaction of men- 
ingococcus lesions to immune serum introduced into the 
spinal subarachnoid space affords additional evidence of 
such a pathway. Lesions along the surface of the meninges 
(the typical meningitis) yield readily to serum adminis- 
tered in this way, whereas lesions within the nervous tis- 
sue, or in portions of the subarachnoid space, which are not 
in direct communication with that portion into which the 
serum has been introduced, do not respond to the same pro- 
cedure. 

Flexner and Amoss 24 in experiments upon the neutraliza- 
tion of the virus of poliomyelitis with immune serum found 
that by the introduction of an immune serum into the sub- 
arachnoid spaces, the virus is capable of being neutralized 
within the cerebrospinal fluid into which it is directly in- 
troduced, or to which it passes in transit from the blood to 
the nervous tissues. In the latter case neutralization prob- 



364 INFANTILE PARALYSIS IN VERMONT 

ably is effected at successive stages in the process of transit 
of the virus from the blood to the nervous tissues. They 
considered it highly probable that the neutralization was 
accomplished before any quantity of the virus became at- 
tached to the nervous tissues themselves, earlier experi- 
ments by Flexner and Lewis 25 having shown that even when 
minute amounts of the virus were inoculated intracere- 
bral^, neutralization was accomplished with very great 
difficulty by intraspinal injections of immune serum. In 
other words, when once attached to the central nervous sys- 
tem tissue, the virus is not neutralized by subarachnoid in- 
jection. 

In connection with this failure of neutralization within 
the brain substance the experiments of Murphy and Sturm 26 
upon the fate of tissue inoculated into the brain are perhaps 
of interest and emphasize the difference in reaction between 
the central nervous system tissue and its adjacent struc- 
tures. They found that a transplantable mouse sarcoma 
grew readily when inoculated into the cerebrum of mice, 
provided the graft did not come in cantact with the ventri- 
cle, in which case a cellular reaction occurred, similar to that 
about a subcutaneous heteroplastic graft. A bit of the ani- 
mal's own spleen inoculated into the brain, along with the 
heteroplastic tumor tissue, prevented the growth of the 
foreign cells. Mice immunized to transplanted tumors were 
inoculated with grafts of mouse carcinoma, both subcu- 
taneously and into the brain. Subcutaneous inoculation pro- 
duced tumors in only 21 per cent of the animals, whereas 
the grafts into the brain produced tumors in 89 per cent. 
Control non-immunized mice inoculated with the same ma- 
terial developed brain tumors in 91.9 per cent and subcu- 
taneous tumors in 82.2 per cent. Thus, mice highly resistant 
to subcutaneous transplants gave no evidence of this re- 
sistance when the tumor was inoculated into the nervous 
tissue of the brain. 



LOCAL SPECIFIC THERAPY IN POLIOMYELITIS 365 

There is now fairly complete evidence that the virus of 
poliomyelitis comes to be attached to a portion of the cen- 
tral nervous system which corresponds to that structural 
area into which immune bodies cannot be made to enter by 
either of the mechanisms of distribution referred to earlier 
in this paper. This seems to offer an explanation for at 
least a part of the lack of success with the serum treatment 
of this disease, and emphasizes the necessity of seeking 
other methods for obtaining a more adequate distribution 
of this serum within the central nervous system. 

THE PASSAGE OF SUBSTANCES FROM THE SUBARACHNOID 
SPACE INTO THE PERIVASCULAR SYSTEM 

Weed 31 found that solutions of potassium ferrocyanide 
and to a certain extent carbon granules in suspension, in- 
troduced into the subarachnoid space, pass into the peri- 
vascular system of the brain when this organ is rendered 
anemic. From this he reasoned that there must be suction 
of fluid from the subarachnoid space to fill the perivascular 
spaces and make up for the loss of fluid in the brain result- 
ing from anemia. Thus, the flow of fluid within the peri- 
vascular spaces which normally is toward the subarachnoid 
space was reversed. The method employed for the produc- 
tion of the anemia was tying the carotids or exsanguination. 
The effects produced were attributed to changes in the os- 
motic relationship between the blood stream and the cere- 
brospinal fluid. Later, Weed and McKibben 23 found that the 
simpler procedure of injecting strongly hypertonic solu- 
tions, such as a 30 per cent solution of sodium chloride into 
the circulation produced a marked reduction in the cere- 
brospinal fluid pressure. This finding indicated that this 
procedure would also serve to reverse the direction of flow 
within the perivascular system, as Weed and Hughson 1 
have shown that the reduction in the cerebrospinal fluid 
pressure is due not to increased absorption of fluid into the 



366 INFANTILE PARALYSIS IN VERMONT 

dural sinuses alone, but to a withdrawal of fluid from the 
tissue spaces into the capillaries. The addition of a foreign 
test solution to the subarachnoid fluid amply confirmed this 
point. When the cerebrospinal fluid pressure was falling 
rapidly or after it had become negative, following the intra- 
venous injection of hypertonic salt solution, two or three 
cubic centimeters of a potassium f errocyanide and iron am- 
monium citrate solution were allowed to flow into the sub- 
arachnoid space. By subsequent fixation of the tissues in 
acidified formalin this solution was precipitated as Prus- 
sian blue at the points which it had reached. The solution 
was found to have passed from the subarachnoid space 
along the perivascular spaces, reaching the interfibrous 
spaces in the white matter and the pericellular spaces in the 
grey matter. 

These experiments, the general findings of which have 
been confirmed by numerous observers, 10 ' 11 ' 12 ' 13 ' 14 ' 38 indicate 
that the intravenous injection of hypertonic solutions of 
sodium chloride brings about new ratios between secretion 
and absorption of cerebrospinal fluid and causes a disloca- 
tion of a considerable quantity of the contents of the sub- 
arachnoid space into the perivascular-perineuronal system. 
They suggested the possibility of obtaining a more effective 
therapy with convalescent serum in poliomyelitis by plac- 
ing it in the subarachnoid space and subsequently injecting 
hypertonic solutions into the circulation. 

EXPERIMENTAL 

The alterations in the fluid circulation of the central 
nervous system which form the basis of our therapeutic ex- 
periments have been made only on normal animals. On ac- 
count of the particular conditions which exist in those 
structures which are chiefly concerned in the alterations 
spoken of in the presence of poliomyelitis infection, there 
was some question as to whether the same alterations would 



LOCAL SPECIFIC THERAPY IN POLIOMYELITIS 367 

be produced in the (Edematous infiltrated tissues of this dis- 
ease. 

Exp. 1. — Macacus rhesus 27 was inoculated* intracerebrally with 
2.5 c.c. of a suspension of glycerolated human spinal cord which con- 
tained the virus (Brow strain). On the ninth day after inoculation, 
the animal showed excitability, tremors, paralysis of the arms. On 
the following day the paralysis had increased in the arms and was 
beginning in both legs. 



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Chart 1. Experiment 1. Monkey 27 in acute stage of poliomyelitis. 
Weight 1320 grams. Ordinates represent cerebrospinal fluid pressure 
in millimeters of water; abscissae represent time in minutes. During 
blocked interval A, intravenous injection of 12 c.c. of 30 per cent solu- 
tion of sodium chloride. During the interval from B to C, introduc- 
tion of 3.5 c.c. of a solution of 0.5 per cent potassium ferrocyanide 
and 0.5 p er cent iron-ammonium citrate. 

*AU inoculations and other operative procedures were carried out under ether anaesthe- 
sia. 



368 INFANTILE PARALYSIS IN VERMONT 

Injection experiment. — Under ether anesthesia (which was main- 
tained at a constant level by insufflation from a Woulfe bottle which 
did not require changing during the course of the experiment) a lum- 
bar puncture was performed and the needle at once connected with a 
U-shaped manometer filled to zero with Ringer's solution. Cerebro- 
spinal fluid pressure was recorded at one minute intervals through- 
out the experiment. After 5 minutes, during which the pressure 
ranged from 84 to 90 mm. of Ringer's solution, 30 per cent sodium 
chloride was slowly injected intravenously. A total of 12 c.c. was 
given in 9 minutes. Within 4 minutes after the beginning of the in- 
travenous injection the pressure rose to 146 mm. of Ringer's solu- 
tion. It then fell rapidly to minus 94 mm. after 27 minutes from the 
begining of the intravenous injection. At this point 3.5 c.c. of a solu- 
tion of potassium ferrocyanide and iron ammonium citrate was intro- 
duced into the subarachnoid space through a burette attached to the 
manometer connection by means by a three-way cock. This solution 
was allowed to run in slowly during a period of 13 minutes. The addi- 
tion of this amount of fluid caused the pressure to rise to plus 67 mm., 
after which it fell within the 6 minutes following to plus 30 mm., at 
which point the experiment was terminated. The tissue was fixed 
and the cyanide-citrate precipitated as Prussian blue by injection in- 
to the aorta of 10 per cent formalin containing 1 per cent hydrochloric 
acid. Microscopic examination of sections showed granules of dye 
distributed in the perivascular spaces. A full report of the distribu- 
tion of the dye will be given in another communication. 

Exp. 2. M. rhesus 23. 

December 6, 1921. Inoculated intracerebrally with 0.5 c.c. 5% sus- 
pension of glycerolated spinal cord of Monkey 
19. 

December 17, 9 A. M. Apparent weakness of right hamstring. 

8 P. M. Partial paralysis of extensors of right 
arm. 

December 18, 10 A. M. Paralysis of right arm and right leg. 

Tremors. Staccato cry. 3 P. M. 7 c.c. 30% 
sodium chloride solution intravenously (1.05 
grams sodium chloride per kilogram). 

December 19, 9 A. M. Condition unchanged. 10 A. M. 6 c.c. 

30% sodium chloride solution intravenously (.9 
grams sodium chloride per kilogram). 5 P. M. 
Condition unchanged. 

December 20, 9:30 A. M. Paralysis stationary in right leg. 

Right arm "improving." 2:30 P. M. 6 c.c. 30% 
sodium chloride solution intravenously (.9 grams 
sodium chloride per kilogram). 

December 25, Slight Improvement. 

The animal recovered with complete paralysis of the right leg and 
a slight involvement of right arm. 



LOCAL SPECIFIC THERAPY IN POLIOMYELITIS 369 



Exp. 3. M. rhesus 18, weight 2 kilograms. 



December 6, 1921. 



December 13, 
December 14, 



December 15, 



December 16, 



December 17, 



December 18, 



Inoculated intracerebrally, right side, with 0.5 
of a 5% suspension of glycerolated cord of Mon- 
key 19. 

6 P. M. Excitable. 

9 A. M. Excitable, head tremors, ataxia. Right 
facial weakness. 11 A, M. Right facial paraly- 
sis. 2 P. M. Paralysis of extensor muscles of 
both arms. Weakness of flexors of right arm. 
4 P. M. 5 c.c. 30% sodium chloride solution in- 
travenously (.75 gram sodium chloride per kilo- 
gram). 

9 A. M. Paralysis of arms increased. 

5:30 P. M. 6 c.c. 30% sodium chloride solution 

intravenously (.9 grams sodium chloride per 

kilogram). 

Paralysis extended in legs. 10 A. M. 6 c.c. 30% 
sodium chloride intravenously. 5 P. M. condi- 
tion unchanged. 

9 A. M. condition unchanged. 8 P. M. Paraly- 
sis has extended. 8:30 P. M. 2 c.c. convales- 
cent serum intraspinally. 

9 A. M. Somewhat improved, general appear- 
ance better. 11:45 A. M. 4 c.c. 30% sodium 
chloride solution intravenously. 11:50 A. M. 
Respiration ceased. 



Exp. 4. M. rhesus 5. 

December 18, 1922. 11:45 A. M. Inoculated intracerebrally with 2 

c.c. of a 10% suspension of glycerolated polio- 
myelitic human spinal cord (Brow strain). A 
needle introduced into the lumbar subarachnoid 
space just before the intracerebral injection 
yielded no fluid until approximately 1 c.c. of 
the virus had been introduced into the cranial 
cavity, after which it began to drop slowly. The 
animal recovered in a few minutes from the 
ether anaesthesia and during seven days fol- 
lowing was entirely normal in appearance. 



December 26, 



9 A. M. Tremors of head. Ruffled coat, excit- 
able. Paralysis of both arms, weakness of back 
and paralysis of adductors of right thigh. 

12 M. Under ether ansesthesia. 20 c.c. of 
30% solution of sodium chloride were injected 
intravenously at the rate of 1 c.c. per minute. 
Immediately after the beginning of the injec- 
tion of sodium chloride solution, a needle was 
introduced into the lumbar subarachnoid space 
and connected to a manometer from which con- 



370 



INFANTILE PARALYSIS IN VERMONT 



valescent serum was allowed to flow into the 
subarachnoid space at a pressure which was 
not allowed to exceed 120 mm. of water. Fifteen 
minutes after the beginning of the injection of 
hypertonic salt solution the serum flowed quite 
rapidly into the subarachnoid space, this con- 
tinuing for thirty minutes, at which time 10 c.c. 
had been used. The animal recovered from 
anesthesia promptly and had a moderate chill. 
Within an hour, although still sluggish, was 
trying to sit up. 

9 A. M. No increase in paralysis. General ap- 
pearance much better than before beginning of 
treatment. 12 M. Treatment was again under- 
taken, but after 12 c.c. of hypertonic salt solu- 
tion had been given intravenously and 4 c.c. of 
serum intraspinally, respiration ceased. 

Exp. 5. M. rhesus 29. 

March 16, 1923. Inoculated intracerebrally with 1 c.c. of a 5% 

suspension of glycerolated brain and cord of 
monkey 5. 



December 27, 



March 30, 



March 31, 
April 1, 



9 A. M. Excitable. Tremors. Weakness in both 
arms. 11 A. M. Paralysis of arms. Marked 
weakness in both legs. 2:50 P. M. Lumbar 
puncture was done and the needle connected 
with a burette-manometer. Cerebrospinal fluid 
pressure was recorded between 85 and 90 mm. 
water. 2 c.c. of human convalescent serum were 
allowed to flow into the subarachnoid space, 
which caused a rise in cerebrospinal fluid pres- 
sure to 130 mm. water. Occipito-atlantoid punc- 
ture was then done and the cerebrospinal fluid 
allowed to drip until its pressure had fallen to 
85 mm. water. The fluid from the occipito- 
atlantoid puncture was at first clear and later 
showed an admixture of serum. Ten cubic cen- 
timeters of 30% solution of sodium chloride 
were then given intravenously at the rate of 
1 c.c. per minute. This caused a rapid reduc- 
tion of cerebrospinal fluid pressure. At inter- 
vals, as the pressure fell, small amounts of 
serum were allowed to run into the subarach- 
noid space so that the cerebrospinal fluid pres- 
sure was not raised above 100 mm. water. 

This animal recovered from the ether anaes- 
thesia promptly but was quite sluggish the rest 
of the day. 

Does not appear ill. Is alert and makes efforts 
to move about. No extension of paralysis. 

General appearance better. Improvement in gen- 
eral appearance in this animal was prompt, 
but there was some paralysis in all extremities 
which persisted. 



LOCAL SPECIFIC THERAPY IN POLIOMYELITIS 371 



Exp. 6. M. rhesus 31. Weight 1420 grams. 
April 7, 1923. Inoculated intracerebrally with 1 c.c. of a 5% 

suspension of the glycerolated cord of Monkey 
No. 5. 



April 16, 



April 19, 



Z2&± 



8 A. M. Excitable. Ruffled coat. Head tremors, 

slight ataxia. 

4 P. M. Same. No paralysis. 

8:30 A. M. Paralysis of extensor muscles of 
both arms and of both legs, more marked in 
right. 11:30 A. M. Occipito-atlantoid puncture. 
3 c.c of convalescent human serum introduced 
into cerebellar cistern, which caused the cere- 




Chart 2. Exp. 6. Monkey 31, in acute stage of poliomyelitis. Or- 
dinates represent cerebrospinal fluid pressure in millimeters of wa- 
ter; abscissae represent time in minutes. During the interval A to 
B 3 c.c. of convalescent human poliomyelitis serum were introduced 
into the cerebellar cistern. During the blocked interval C, cerebro- 
spinal fluid was released from the subarachnoid space through lum- 
bar puncture. During the blocked interval D, 13 c.c. of a 30% solu- 
tion of sodium chloride were injected intravenously. During the in- 
terval E to F 7 c.c. of convalescent human poliomyelitic serum were 
introduced into the subarachnoid space. 

M. rhesus No. 30, Control for No. 31. 



372 INFANTILE PARALYSIS IN VERMONT 

brospinal fluid pressure to rise to 270 mm. wa- 
ter. This caused some respiratory embarrass- 
ment, which was relieved by lumbar puncture 
with a reduction of cerebrospinal fluid pres- 
sure to 115 mm. water. 13 c.c. of 30% sodium 
chloride solution intravenously at the rate of 
2 c.c. per mm. Cerebrospinal fluid pressure rose 
to 165 mm. water and then fell rapidly to minus 
16 mm. water. 7 c.c. convalescent serum slowly 
introduced into the cerebellar cistern. 4 P. M. 
Somewhat slow but gets about cage. 12 c.c. con- 
valescent serum intravenously. 

April 18, Sitting up. Appears bright. No extension in 

paralysis. 

April 19, Improved. Gets about with ease. 

May 17, Recovery with partial paralysis of right leg. 

April 7, 1923. 3:15 P. M. Inoculated intracerebrally right 

side with 1 c.c. 5% suspension of glycerolated 
cord of Monkey No. 5. 

April 17, 8 A. M. Excitable, marked head tremors, mod- 

erate ataxia. 9 P. M. Excitable, marked head 
tremors, more ataxic. 

April 18, 9 A. M. Excitable, tremors, more ataxic; misses 

hold. 

April 19, 9 A. M. On floor. Flaccid paralysis of ex- 

tensors of arms. Flexors good. Some weakness 
of legs. 

April 20, Both legs flaccid. 

April 21, Down, barely able to move arms. Appears ill; 

head tremors. 

April 22, Paralysis same. Head tremors. 111. 

April 23, Paralysis same. Head tremors. 111. 

April 24, Paralysis increased. Almost prostrate. Head 

tremors. 

April 25, Some edema under eyes. Some tremors. 

April 27, Same. 

April 28, Same. 

Gradual subsidence of acute symptoms. Unable to use extremities 
except hands. Gets about cage by pulling with hands and twisting 
body. Remained in same condition until May 17. 

May 17, Sits up. Uses both arms and one leg fairly well. 



LOCAL SPECIFIC THERAPY IN POLIOMYELITIS 373 
SUMMARY AND DISCUSSION 

The experimental findings presented indicate that the 
intravenous injection of strongly hypertonic solutions of 
sodium chloride causes marked alterations in the circula- 
tion of fluid within the central nervous system of monkeys 
in the acute stage of poliomyelitis (Exp. 1). These altera- 
tions are apparently similar to those reported by other ob- 
servers in normal animals, namely, reduction of cerebro- 
spinal fluid pressure, reduction in the volume of the brain 
and spinal cord (removal of fluid) and a reversal of the cur- 
rent of fluid within the perivascular spaces. 

Reduction in the volume of the brain and spinal cord sug- 
gested the use of hypertonic intravenous injections as a 
means of reducing to some extent the edema of the central 
nervous system tissue in acute poliomyelitis. However, it 
is realized that factors other than osmosis are involved in 
edema. The course of the disease in one monkey treated in 
this manner (Exp. 2) as compared with the control animal 
in this series (Monkey 30), inoculated with the same strain 
of virus, is indicative of a beneficial effect of hypertonic 
solutions on the course of the disease. 

Experiments 3 and 4 were designed to make use of the 
reduction in volume of the brain and spinal cord for lessen- 
ing the edema as suggested by the previous experiment and 
at the same time to replace the contents of the subarachnoid 
space with human convalescent serum which would be 
drawn into the perivascular spaces, under the influence of 
the hypertonic solution, and thus bring about a distribution 
of the serum, which does not take place after administra- 
tion by other methods. In both these animals there was evi- 
dence of improvement following treatment, but unfortu- 
nately attempts to repeat the injection of relatively small 
amounts of hypertonic sodium chloride solution caused 
death of the animals. 

Experiment 5 was carried out in the same manner as 



374 INFANTILE PARALYSIS IN VERMONT 

Experiments 3 and 4 except that only one injection was 
given. As shown on the protocol, this monkey had marked 
involvement when treated, but his condition on the follow- 
ing day was strikingly better. Recovery, although accom- 
panied by a considerable degree of paralysis, was prompt 
as compared to the slow recovery of the control monkey 30. 
Experiment 6 was a repetition of Experiment 5 with the 
addition of an intravenous injection of serum given 3 hours 
after the injection of hypertonic salt solution; in order that 
antibodies would be present in the blood when the flow of 
fluid from the circulation to the central nervous system fluid 
spaces was re-established. This animal showed an almost 
immediate improvement. There was no extension of paraly- 
sis after the one treatment, and recovery was rapid with 
only a partial paralysis of the right leg. As compared with 
the usual course of the disease in monkeys the outcome of 
this experiment is regarded as very favorable. 

CONCLUSIONS 

This small series of experiments indicate that the use of 
intravenous hypertonic solutions in conjunction with intra- 
spinous convalescent serum has a favorable influence on the 
course of experimental poliomyelitis. This effect is aug- 
mented by the intravenous injection of convalescent serum 
at a time corresponding to the compensatory increase in 
passage of fluid from the circulation to the central nervous 
system tissue. 

The optimal conditions in respect to the administration 
of hypertonic solutions remain to be worked out. 

Daily repetition of hypertonic sodium chloride solution is 
associated with danger of respiratory failure. 

References 

"Weed, L. H., and Hughson, W.: Am. Jour. Physiol., 1921, LXIII, 1. 

2 Levaditi and Landsteiner: Compt. rend. Soc. biol., 1910, LXVIII, 
311. 

Romer, P. H., and Joseph, K.: Munch, med. Wnschr., 1910, LVII, 
568. 



LOCAL SPECIFIC THERAPY IN POLIOMYELITIS 375 

3 Flexner, S., and Amoss, H. L.: Jour. Exper. Med., 1917, XXV, 499. 

4 Flexner, S., and Clark, P. F.: Jour. Amer. Med. Assn., 1911, 57. 

5 Draper, G., and Peabody, F. W.: Am. Jour. Dis. Child., 1912, III, 
153. 

6 Clark, P. F., Fraser, F. R., and Amoss, H. L.: Jour. Exper. Med., 
1914, XIX, 223. 

7 Anderson, J. F., and Frost, W. H.: Jour. Amer. Med. Assn., 1911, 
54: 663. 

"Flexner and Amoss: Jour. Exper. Med., 1917, XXV, 525. 

Tlexner and Lewis: Jour. Amer. Med. Assn., 1910, 54: 14. 

10 Cushing and Foley: Proc. Soc. Exper. Biol, and Med., 1920, XVII, 
217 

"Sachs and Belcher: Jour. Amer. Med. Assn., 1920, 75: 667. 

"Foley and Putnam: Am. Jour. Physiol., LIII, 464. 

"Ebaugh and Stevenson: Johns Hopkins Hosp. Bull., 1920, XXXI, 
440. 

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